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THE
DUBLIN QUARTERLY JOURNAL
OP
MEDICAL SCIENCE.
I
6
THE
DUBLIN QUARTERLY JOURNAL
OF
MEDICAL SCIENCE.
VOL. XXXIII.
FEBRUARY AND MAY, 1862.
DUBLIN :
FANNIN AND COMPANY, GRAFTON- STREET.
LONDON: LONGMAN & CO.; SIMPKIN, MARSHALL & CO.;
J. W. DAVIES.
EDINBURGH : JOHN MENZIES ; MACLACHLAN & STEWART.
1862.
DUBLIN :
JOHN FALCONER, PRINTER, TO HER MAJESTY'S STATIONERY OFFICE, 5^, IT. SACKVILLE-ST.
31
1%
7J.S.
i 1 1 1 :
DUBLIN QUARTERLY JOURNAL
OF
MEDICAL SCIENCE.
--*■—
CONTENTS.
No. LXV.— FEBRUARY 1, 18G2.
Part I.— ORIGINAL COMMUNICATIONS.
PAGE
Art. I. — Reports in Operative Surgery. By Richard G. H. Butcher,
Esq., M.R.I.A., F.R.C.S.L ; Chairman of the Surgical Court of
Examiners, and Examiner on Surgery in the Royal College of
Surgeons in Ireland ; Surgeon to Mercer's Hospital ; and Lecturer on
Clinical Surgery : —
On a New Operation for Removal of Deformity after Burns. —
Resections of the Femur and of the Tibia. — Complicated
Amputation of the Leg — The Treatment of Pyemia. With
Illustrations, ....... 1
Art. II — Observations on Epistaxis. By Rawdon Macnamara, M.R.I. A.,
Professor of Materia Medica, R.C.S.I., and one of the Surgeons of
the Meath Hospital, &c, . . . . . 28
Aur. III. — On the Radical Cure of Reducible Hernia. By Redferx
Davies, M.R.C.S. Birmingham. With Illustrations, . . 60
Am. IV. — On Complete Resection or Extirpation of the Astragalus. By
Dr. Oscar Heyfxideb, of St. Petersburgh, . . . .67
Art. V. — An Essay upon the Malformations and Congenital Diseases of
the Organs of Sight ByW. R. Wilde, M.D., V.P.R.I.A., F.R.C.S.,
Surgeon to St. Mark's Ophthalmic Hospital, Honorary Member of the
Medical Society of Stockholm, &c, &c With Illustrations. Part
IV. (Concluded from vol. xxxi.. p. 74), . . . .71
I
r \'.i
\kt v 1 On Carbonic Acid in Mineral Wafc By J \i m u v M D
il ( lollege of l'li_\ ucians of London, &
Am Vll. Obteo "ii Encysted rumours. B) Hbbxsi taosr,
Mill l; * S.1 I. K vv Q ( P.I., Letterkenny, . Bl
Aur. VIH. — On - bh< Watering Placet and other Health B
fSwitzerland. l>v H. R. de Ricci, M.D. (Continued from vol. axxiL,
p. 3 . • • .
Pabt IL— REVIEWS AND lil liLK )( ; K A IM IK A L NOTICES.
1. Observations in Clinical Surgery. By Jambs Stmb, Professor of
Clinical Surgery in the University of Edinburgh,
•J. Do Hallucinations, ou Histoire Raisonnee des Apparitions, des Visions,
des Songes, de I'Extase, des Reves, de MagnCtisme et de Somnam-
bulisme. Par A. Bbibbbe de Boismort, M.D., . . 102
;>. Return to an Order oi the Honourable the House of Commons, dated
5th August, 1861, tor Copj of tin- Papers relating t>> Quarantine,
Communicated to the Board of Trade, on the 30th of July, 1861.
Blue Book, . . . . . . . .119
4. A Practical Treatise on the Use of the Ophthalmoscope. By J. W.
Hulks, F.R.C.S •' HA
.'). On the Treatment of Fracture of the Lower Extremity of the Radius.
By Alexander Gordon, M.D., L.R.C.S. Edinburgh, &c, . 1 "27
6, Manual of the Dissection of the Human Body. By Luther Holdj
F.R.C.S., & ...'.... 130
7. On Venereal Diseases: —
i. The Modern Pathology and Treatment of Venereal Diseases.
By Patrick Heron Watson, Assistant Surgeon to the Royal
Infirmary, &c, . . • • • .135
n. On the Relative [nfluence of Nature and Art, in the cure of
Syphilis. By Thomas Wbedon Cooke, Surgeon to the Royal
Free Hospital, &C, . • . . . .135
m. On the Successful Treatment of Gonorrhoea and Gleet, without
Copaiba. By Thomas Weedon Cooke, Surgeon to the Royal
Free Hospital, &C, . • • . • .135
8 Memorial de Therapeutique. A ['usage des Medicins Praticiens.
Parle Doctbub F. Fot, ...... 140
( \> ii Irnls. iii
P kGE
!». Papen on Chemistry. By Maxwell Simpson, M.B., T.C.D., &c,
formerly Lecturer on Chemistry in the Park-street, and the Original
Schools of Medicine, Dublin: —
i. [Jeber ewei neue Methoden sur Bestimmungdes Stickstoffs in
organischen and unorganischen Verbindungen. A.nnalen dcr
Chemie and Pharmacie Bd. xcv., p. 63, . . .14
ii. Note concernanl Paction du Brome sur I'lodure d'alde'hydenc.
Comptes Etendus, Tome xlvii. Seance du I Mars, 1858, . Ill
m. Sur one base nouvelle obtenue par Faction de L'ammoniaquc
sur le tribromure d'allyle. Annales de Chimie et de Physique,
3rd Serie, t. hi., and Philosophical Magazine, Oct. 1858, . I 14
iv. Action du Chlorure d'acetyle sur l'aldchvde. Comptes Rendes,
Tome xlvii. Seance du 29 Xovembre, 1858, . . .144
v. On the Action of Acids on Glycol. Proceedings of the Royal
Society, Nos. 34 and 30, 1859, . . . . .144
vi. On the Synthesis of Succinic and Pyro-tartaric Acids. Philo-
sophical Transactions, 1861, p. 61, . . . .144
10. Lectures on the Germs and Vestiges of Disease, and on the Prevention
of the Invasion and Fatality of Disease by Periodical Examinations.
By Horace Dobell, MD', . . . .1 4?)
1 1 . Ethical Writings of Physicians : —
i. Aspirations from the Inner, the Spiritual Life; aiming to
reconcile Religion, Literature, Science, Art, with Faith, and
Hope, and Love, and Immortality. By Henry- M'Cormac,
M.D., [61
ii. Les Medecans Moralistes Code Philosophique et religieux,
extrait des Ecrits des Medecins anciens et modernes notam-
ment des Docteurs Francois contemporains. Par Madame
YVoillez, . . . . . . .161
Part III MEDICAL MISCELLANY.
Retrospect of the Progress of Surgery during the last Decade. By
Maurice Henry Cojli,is, M.B., F.R.C.S.I., Surgeon to the Meath
Hospital and County Dublin Infirmary ; Member of Council R.C.S.I.,
and of Council of Surgical Society, . . . . .1 63
Transactions of the Association of the Fellows and Licentiates of the Bong
and Queen's College of Physicians in Ireland: —
Dr. Cobrig m on the Treatment of Hydrophobia in Greece, 193
Du I imjRCHLLL on some of the Reflex Irritations resulting from
I icrine Disease, ...... log
Dr. Osrorke on the use of the Harrowgate Waters, . . 99
'
!
Mi;. ( .11 1 •
1,: aral Paralysis of tin- inu
M v s \m v.. v on Aneurism oi
pfl \; i on Cii th • Liv<
.
Mi;. 1!
200
of the Dublin Obstetrical Soci( t\ :—
1)k. M-i'i iMo. k en Tumours of the Labia, Clitoris, and Va
\\ iih Illustratioi . . . . ■
Dr. J. A. Byrne— Cas< of Rupture of the Uterus in whicl
■ Iv place. .
Dr. M m Swinei on a ] I tur oi the Uterus,
fransactions of the County and City of Cork Medical and Surgica
Annual i by the President, Dr. Popham,
Dr. Bernard on Aneurism of the Aorta,
Dr. Finn on True Thoracic Aneurism, &c,
Biographical Notice of Henry Pierrepoint, Marquis of Dorchester,
time Felloe of th*' Royal College of Physicians, London.
IJ\ Dr. Belcher, ......
227
227
236
238
240
Clinical Records an ! Translations: —
A Case of Occluded Vagina By J. 11. Houghton, M.R.C.S.E.,
Dudley, . .
A Case of the Radical Cure of Reducible Hernia, l>\ Wood's
Method. By William Colles, Surgeon to Steevens's Hospital,
Aphonia in Tuberculosis of the Lung. Bi Professor Mandl, . 244
in jtUmou'am,
Medical Superintendence of Asylums,
Books Received— Exchange List, .
Notices to Correspondents,
. 24.5
. 259
270
. 272
i ! 1 1 ;
DUBLIN QUARTERLY JOURNAL
OF
MEDICAL SCIENCE.
CONTENTS.
No. LXVL— MAY 1, 1862.
Part I.— ORIGINAL COMMUNICATIONS.
PAGB
Art. IX — On the Employment of a Heated Thermometer for the Measure-
ment of the Cooling Power of the Air on the Human Body. By
Jonathan Osborne, M.D., King's Professor of Materia Medica, &c., 273
Art. X. — On the Statistics of the Mortality of Fractures of the Skull ;
Effects of Operation, &c, &c. By Henry Murney, M.D., Surgeon
to Belfast General Hospital ; President Belfast Clinical and Patho-
logical Society; formerly Demonstrator of Anatomy Queen's Col-
lege, &c, &c, . . . . . . .281
Art. XI — Hospital Reports. By John Hughes, M.D., Senior Physician
to the Mater Misericordiae Hospital. ..... 296
Art. XII — On Cellular Polypus of the Ear. By J. G. IIildige, F.R.C.S.I.,
Surgeon to the National Eye and Ear Infirmary, . . 306
Art. XIH — Observations on Acute Gangrene, resulting from Compound
Fracture of the Leg. By Samuel G. Wilmot, M.D., F.R.C.S.L,
Surgeon to Steevens' Hospital, &c, &c, . . . .311
Art. XIV — Commentaries on Diseases of the Heart and Vessels. By
Robert D. Lyons, ......". 320
K.V. — ii l B.,
I R.C.S.] Physi iao to the Richmond, Whitworth, and Hardwicke
II from vol. vvii., p, 34M), , ;j-tu
\\ 1 Clinical Reports and Observations on Medical ( Bj .1
1 i ' D r.C.D., Kin ■'■ Professor of the Practice of Medi-
due, V.V*--, A
Ai.r W II -Uu a Double-bell Stethoscope. Bj Robjiet D . 3»;4
Past II.— REVIEWS AM) BIBLIOGRAPHICAL NOTICES.
1. Sulle Malattie da Fermento Morbificoe Sul Uwo Trattamento. Me-
moria del Dr Giovahitj Poixi. ..... 367
1, Reformatories for Drunkards, ...... 374
i I 'a Uncontrollable Drunkenness, relative to Medico-L
Arrangements. Read before the Social Science Congress, L861.
By Thomas Lewis RIackesy, M.D.
II. On Chronic Alcoholic Intoxication, or Alcoholic Stimulant
in connexion with the Nervous System. B) W. BIaecbt,
M.D., F.R.S., Fellow of fhe Royal College of Physicians, &c
London. I860.
in. Some Facta which suggest the idea that the Desire tor
Alcoholic Stimulants is not only transmitted by Hereditary
Descent, but that it is also felt with increasing force from
generation to generation, and thus strongly tends to deteriorate
the Human Race. A Paper read before the Dublin Statistical
Society, on the loth of February, 1858. By James 11 LUGHTON.
iv. The City — its Sins and Sorrows, &C. By Thomas (Jitiikie,
\)A) Edinburgh 1857.
3. Placenta Previa; its History and Treatment. By William Kead,
M.D., &c, &C., . . . . • .391
4. Etudes sur le Catheterisme Curviligne et but I'emploi d*une Nouvelle
Sonde, dans le Catheterisme Fvacuatif Par le Dooteur J. A. Gely, 398
5. On the Parasitic Affections of the Skin. By T. MCall Andeuson,
M.D., && . . . . . 401
G. Recent Manuals of Chemistry : — ..... 403
i. A .Manual of Chemistry, Descriptive and Theoretical. By
William Odling, M.B., F.K.S., &c, &c, &c. Parti.
ii. An Introduction to Practical Chemistry, including Analysis.
By John E. Bowman, F.C.S., &C., &C. Edited by Charees
L. Bloxam, Professor of Practical Chemistry in King's Col-
lege, Loudon.
( 'ontents. iii
PAOl
7. Precis Iconographique Dei Maladies V^neriennea. Par M. A. Gul-
i.r.Kiri;. Chirurgien <lc Ilojiilal du Midi, &C, &C, . . . 40G
8. Consumption, ils I\;ul\ and Remediable S(.iLr'<. By Bd. SMim,
M.D., 4c, 408
Paw III— MEDICAL MISCELLANY.
Retrospect of the Progress of Surgery during the last Decade. By
Maurice Henry Collis, M.B., F.R.C.S.I., Surgeon to the Meath
Hospital and County Dublin Infirmary ; Member of Council R.C.S.I.,
and of Council of Surgical Society. (Continued from page 192), . 417
Transactions of the Association of the Fellows and Licentiates of the King
and Queen's College of Physicians in Ireland : —
Dr. Beatty on So-called Hydatids of the Uterus, . . 445
Dr. Duncan on Obstructive Disease of the Heart, . . 445
Proceedings of the Pathological Society of Dublin : —
Dr. Hamilton on Intra- Capsular Fracture of the neck of the
Femur, ........ 450
Dr. M'Clintock on Fibrous Tumours of the Uterus, . .451
Dr. Moore on Diabetes, ..... 453
Dr. Hayden on Phthisis — Tubercular Abcess finding exit through
the intercostal space, . . 455
Dr. Hamilton on Syphilitic Laryngitis, .... 456
Dr. MacSwiney on Disease of the Mitral and Semilunar Valves, 457
Dr. Bannon on Contraction of the Left Auriculo-Ventricular
Opening, ....... 459
Proceedings of the Dublin Obstetrical Society : —
Dr. Minchin on Distorted Infantile Cranium, . . . 460
Mr. Tufnell on Extra Uterine Fetation, . . . 462
Dr. Kidd on Congenital Tumour of the Head, . . . 464
Dr. Halahan on the Mechanism of Labour, . . . 467
Transactions of the County and City of Cork Medical and Surgical
Society : —
Dr. Popham on Rigidity of the Left Lower Extremity from
Anchylosis ; Caries of the Bones of the Ankle Joint, . . 470
Dr. Willett on Cirrhosis of the Liver, . . 472
Mr. Belcher on the Treatment of Psora in Military Hospitals, 474
t\
' lical and - . —contin
Difficult Labour, from Malformation
the Pelvis, complicated with a uterine Polyp
Da. \\ 11 i.j.i i on Hematuria, ... 478
Da, Fnrx on Mulberry Calculus, .... 479
l)u Potham on soi i of Diphther . . 4«0
Transact ions ol the Belfast Clinical and Pathological Society: —
\)n. Baowai i»u Cataract,
Da. Baowws on EnohondrOma of Hand,
Fkofessou (roHDON on Fracture of Clavicle,
Dk Bkowm; on Fracture of Tibia and Fibula of the Right Leg,
Da. Baowaa on Disease of Hand,
Da. BaowRi on Compound Comminuted Fracture,
Paoraasoa (Iorjjon on Epulis, ....
Da. Baowax on Disease of Femur,
Da. Browne on Extroversion of Bladder,
Da. Browne on Excision of the Tonsils,
483
483
484
485
486
487
487
488
489
490
Debout on Restoration of Congenital Fissure affecting the Hard and Soft
Palates 490
Books Received,
. 513
Notices to Correspondents,
514
Index,
515
I
I
H
••'
fat
%
x *\
S
J
atelier on anew operation for the Cicatrical tissue after Burns.
THE
DUBLIN QUARTERLY JOURNAL
OF
MEDICAL SCIENCE.
FEBRUARY 1, 1862.
PART I.
ORIGINAL COMMUNICATIONS.
Art. I. — Reports in Operative Surgery. By Richard G-. H.
Butcher, Esq., M.K.I. A., F.R.CS.I. ; Chairman of the Surgical
Court of Examiners, and Examiner on Surgery in the Royal
College of Surgeons in Ireland ; Surgeon to Mercer's Hospital ;
and Lecturer on Clinical Surgery.
1, 2. CASES OF EXTENSIVE CICATRICAL DEFORMITIES AFTER
BURNS, ILLUSTRATIVE OF SPECIAL FORMS OF OPERATION.
3. SHOCKING DEFORMITY AFTER BURN — THE HEAD BOUND DOWN
TO THE SHOULDER — PERFECTLY CURED, WITH SCARCELY A
TRACE OF DEFORMITY, BY A NEW OPERATION.
4. REMOVAL OF SIX INCHES AND A HALF OF THE SHAFT OF THE
THIGH BONE ; LIMB RESTORED TO NEARLY ITS FULL LENGTH,
AND CONSOLIDATED BY THE APPLICATION OF BUTCHER'S
SPLINT.
5. EXTENSIVE CARIES OF THE UPPER AND LOWER END OF THE
TIBIA; EXCISION AND GOUGING OUT OF THE DISEASED BONE ;
PERFECT RECOVERY, WITH THE FUNCTIONS OF THE KNEE
AND ANKLE JOINTS PRESERVED.
VOL. XXXIII., NO. 65, N. S. B
Mi: Butch] Operativ
•ii-i.n vi 1.1 1 IMPUTATION OJ i in. LEG K) BAVI 1 m. km i.
join l ; 1.k;a i l i;i 01 I HE POPU 1 ! . \: Bl UB ▲ 81
n Ml i\ i;i .. I »\ l.lii
7. on mi. iki.wmi.m OP PYEMIA Bl KEBCUB1 UO) STIMU-
LANTS
The deformities resulting from the contraction of the cicatrical
tissue, reparative after burn-, has attracted, over and over again, the
attention of practical Burgeons towards remedying tin- evil
patiently investigating the development of the process, and, upi.u
acquired knowledge, striving to establish a mode of treatment
likely to prevent the change, and to Becure, as far as possible, the
normal restitution of the part after the injury inflicted ; while oth<
have -trained their ingenuity, judgment, decision, and operative
skill to remove the distortion. Bet t'wa unnatural connexion-, and
thereby restore lost functions to members, to organs, and to part-.
In the whole range of surgery, so interestingly taught and elucidated
by Dupuytren, there is not one subject which, in my opinion, he has
handled with so great a grasp and power as the accident and its
consequences under consideration — Hums. Surely the risks to
which the poor sufferer from burn is exposed, primarily and secon-
darily, must call forth our warmest sympathies, our best exertions.
From the time of the infliction of the injury to the cicatrization of
the part weeks and months must elapse — from the time of the
infliction of the injury to the cicatrization of the part hours, days,
weeks, and months of pain and Buffering must be passed through;
and yet not all — danger constantly lurks round the sufferer; and
often death seizes on the creature just as repair is accomplished,
and we are about to exult in the successes of our practice.
Who, when a bad case of burn is confided to him, does not watch
with apprehension the shock — the threatened, and often fatal,
svneope — the imperfect or nervous reaction — the patient sinking
exhausted under febrile tumult of the asthenic kind; or the decep-
tive lull which, in many instances, precedes this form of reaction, as
we see illustrated sometimes in the old, — they may walk after the
accident, yet be dead in 48 hours; or again, reaction of the sthenic
type proving excessive, and life being endangered by the violence of
inflammatory fever. And oh ! how many perils threaten during
the progress of this fever, by the implication of internal organs,
especially the lungs, heart, and pericardium, the brain, and, later
agaiu, disease, extensive, of the intestinal mucous membrane, often
Mi:. BUTCHER'S Reports in Operative Suiyrn/. 3
sufficient of itself to destroy life; and later still, more surely and
certainly, isolated to a part, perforation of the bowel. Many dangers
passed over, yet, remotely, in the end. tedious cicatrization, con-
finement, :m<l discbarge, are prone to peril the system by hectic;
or the patient may die suddenly, eieat ri/ation being nearly or entirely
completed, and in a manner Unaccounted for, even on dissection;
while at any period throughout this Struggle tetanus may supervene,
and. as 1 have illustrated in the pages of this Journal by numerous
S, with but little prospect of remorse or subsidence.
Death escaped, life may be rendered very miserable by the
deformity and impairment of function often inseparable from healing
of the burn.
Diversified as arc the deformities from burns, Dupuytren is of
the opinion that they may all be referred to five classes : —
1. Those in which the cicatrix is too narrow.
2. Those in which it is too prominent.
3. Those in which it has formed extensive adhesions.
4. Those in which a cavity has been obliterated.
5. Those in which organs, or an organ, has been destroyed.
Springing from this extensive range, it may readily be surmised
that the operations proposed must be varied and modified to suit
the case. It is not my purpose here to dwell upon the complicated
measures that may be demanded to rectify the vicious union —
incision — excision — free detachment of the widely and deeply con-
necting bands — subcutaneous sections — excision of the cicatrix
when limited — semilunar vertical incisions in the sound skin on
either side, to permit of the wound being brought together, the
edges adjusted, as in the urethro-plastic operation practised by
Dieffenbach, and in that recommended by Gay, to facilitate the
contracting process in old ulcers with matted edges and boundaries —
transplantation of healthy structures, to fill up and cover in the gap
the flayed part exhibits either after excision or transverse disunion,
accompanied by traction sufficient for the restoration of symmetry.
Many of these I have put into execution, several resulting in
unparalleled success ; and I am deeply impressed with the conviction
that, by well-timed, well-planned, and boldly executed operations,
closely followed by careful, sedulous dressing, and adjustment of
mechanical appliance, according to the exigency of the case, more
may be expected and achieved, than even has hitherto been accom-
plished in this most interesting, yet lamentable, department of our
art. I shall now dwell upon the operation which I wTish to bring
b 2
1 M :: Bl i I HER - U
purtioularl) forward, as novel in it- character, and possessing man)
advanl ukI applicable in cases of prominent cicatrices, be tl
thin or massive in their proportions. Before doing so, however 1
ihall detail two remarkabl - which, bj comparison, become
valuable, and their mention here most appropriate, u introducl
to the particular mode of proceeding 1 wish to inculcate.
\ i are ago — 1 take the date from mj case-book, November 29,
1845 — a young man was admitted to Mercer'a Hospital with
hideous deformity after burn, analogous, in many respects, to the
- - which 1 shall presently detail, as to the nature of this distortion,
but felling far short of it as to the abundant shedding, development,
and contraction of the cicatrical tissue. The patient, William
Smith, aged 1<» years, had been burned severelj five years before
the date of his admission — his clothes bavins ignited as be fell
asleep upon the hearth-stone before a large fire in his cabin —
destruction of all the tissues on the left side of the neck resulted;
protracted suppuration; gradual, slow, yet progressive cicatrization
followed; contraction and deformity. The head soon was dragged
down to the shoulder; or, when the head was raised to its proper
position, then the shoulder was drawn up, being unnaturally elevated
. eral inches above its fellow; the cheek, the mouth, the eve, the
ear, were all drawn to the affected Bide. The whole condition of
the part, the countenance, and expression of tin- patient are admirably
represented in Plate II., Fig. 1, the drawing being taken from a line
cast in my collection. The following operation was performed the
dav after his admission, by the late Mr. Tagert. He made two
incisions through the web, removing a large triangular or A' shaped
piece, the base three inches in length externally at its free edge, the
angle close to the neck. Wherever the slightest tension presented
itself, on the head being placed in the erect and natural position with
the shoulder depressed, it was cut ; every seam or root of the cicatrix,
wherever straitened, was set free. "When the necessary incisions
were completed the exposed surfaces were much greater than could,
by possibility, have been anticipated. The head, after this extensive
dissection, was easily restored to the straight position, but the left
eye and angle of the mouth were not much altered or materially
rectified towards a better condition. After a few days, the report
goes on to say, ik An apparatus was applied to keep the head up
from the chest, and towards the healthy side ; it consisted of two iron
wings, well padded, concave, to embrace each temple, connected
posteriorly to a back piece which, interiorly, passed off in two
Mi:. Butchbb's Reports in Operative Surgery. 5
expanded concave plates, to rest one upon each shoulder; the back
piece had a movable slide upon it, so as to permit the neck-piece to
he Lengthened when necessary; and connected with the head plates,
where they Were attached to the hack piece, was a horizontal screw
bj which the head could he elevated from, 0T depressed to, either
shonldcr. The lower (aid of the hack piece was retained in place by
a strap buckled round the chest, and the chin was supported by a
strap and buckle, connected from one temporal plate t<> the Other."
This patient was retained in the hospital for five month-, tin; part
cicatrized, the greatest care apparently carried out in the dressing
of the wound. &c., in a word, in its management, yet, at the end
of the report, I find, " Dismissed March 30th, not much improved"
In the catalogue of my museum I find the following report
attached to the number of the cast, taken from the patient previous
to operation: — " Cast No. 53: Distortion, the effect of severe burn.
The subject of the injury was a young man aged 16 years, who had
been severely burned, five years before, over the entire side of the
neck ; the present deformity is the result of the cicatrization of the
part. The following operation was performed, but without much
success: — A V shaped incision was made through the web, the ba sc-
at its free margin, and the part removed. After this, wherever the
integuments seemed tightened, the incisions were extended so as to
liberate them freely ; the exposed surface, after this proceeding, and
on placing the head inclined to the right side, was far greater than
could have been anticipated as the result of the incisions; the
dragged condition of the eye and mouth were not, however, much
benefitted, though the greatest possible care was taken in the
dressing of the wound, and the nicest application of mechanical
means to keep the head erect, and somewhat to the sound side ; yet
I must proclaim that little benefit was derived from the operation ;
though the patient left the hospital, after five months, considerably
improved ; yet, when I had seen him at a period of six months later,
the web was nearly as prominent as before the operation, as
indurated and unyielding in its nature."
I shall next detail the steps of an operation, with its results,
which I performed on a boy aged three years. The principle of
this method was recognised by Celsus; and certainly, in my hands,
was followed by a considerable amount of success. The reason why
I dwell upon it at all — why I select it from amongst several cases
cut after various fashions — is, that it approximates more closely than
any other the operation which I shall presently describe, and which
Mi: BUTCHJ p&rti 11 ' r.j.Tfj
1 claim for nay name: it- success only illust] i the
. a limited amendment, while mine fields a perfect
koration to norma] position; neither, however, can bring back the
Datura] colour, or remove the pitting- that bo frequently exist ai
the destructive influence of intense heat.
('\-i II — Extensive Cicatrix after Bum, Binding Down the Chin
to the Sternum, Rectified by Operation.
John B , aged eight years, admitted to Mercer's Hospital, June,
L860. Three yean before, he was severely burned abou^ the throat
and chest — hifl clothes having taken tire in front. He presented, on
admission, a very pitiable appearance; hif chin was bound down
literally to the first bone of the sternum, BO that the month v.
kept open, and the lower lip not only dragged downward- but
prominently forwards; a strong, dense band of cicatrical tissue i
tended from the chin, in a puckered form, dragging down cheeks,
month, lower jaw, and becoming expanded b\ wide-spread elaw.s
upon the fore-part of the chest, implicating deeply the internment
over the upper thoracic region. So matted was this structure
throughout the neighbouring parts, that the slightest attempt to raise
the head produced additional depression of the cheeks, and even
lower lids, distorting the eyes frightfully; the effort prolonged drew
up the clavicles and shoulders. The simple deduction being amply
demonstrated by the wide-spread and unyielding nature ot the
morbid connecting medium. For the appearance of the boy
previous to operation, see Plate II., Fig. 2.
On the 20th of the month 1 operated after the following
method: — The child, having been placed lying on the operating
table, was quickly brought under the influence of chloroform; the
knife was applied over the fore part of the chest by a semicircular
sweep, about four inches transversely, the cornna of the curve being
a little below the centre of the clavicle on either Bide, while its
concavity embraced all the dense and central portion of the i spanded
cicatrix below, and fully an inch beyond of healthy structure. The
depth of the incision went through the integument and fascia. This
extensive flap was then dissected up; the head, at the same time,
being elevated, and shoulders depressed, to make tense the binding
shreds beneath. It was remarkable how quickly the parts retracted
under the touches of the knife, and how high the flap ascended
exposing actually the entire lower region of the neck ; even as the
-*■
Fig. 2
<^*5i8s&
■
. •
IflSi
p
Mr Butcher on anew operation far the Cicatrical tissue after Bums.
Mu. BUTCHER'S Reports in Operative Surgery. 7
parts were now exposed portions of the fascia had to be carefully
cut through; and even some of the anterior fibres of the mastoid
muscles on both right and left sides :i little above their clavicular
attachment; and, though closely in the proximity of the main vessels
of the neck, restraining bands were sought out and divided; by a
tedious dissection of this kind the head was got into its natural
position. The gaping wound and the exposed healthy parts over the
sternum were dressed with lint soaked in oil, and retained by a few
turns of a bandage obliquely across the chest, and in a circular
manner round the neck ; outside this dressing was placed a piece of
pasteboard, cut in the form of a stock, rolled in a piece of French
wadding and linen outside, so as to make a stiff collar, and thus
secure the head from being approximated to, or drooping on, the
chest . A few days after this operation I freed the lower lip from
the chin by subcutaneous section, and restored it to its proper place.
The effect of the two operations was most marked for good on
the entire countenance ; the case went on without any unfavourable
symptoms ; pressure, caustics, astringents, &c., being applied, accord-
ing to circumstances, and the continued use of the collar persevered
in. After a period of little more than four months the parts healed
wonderfully well, the entire wound over the sternum and lower
part of the neck being covered in by new structure ; the motions of
the head were nearly restored, and the deformity of the countenance
all but removed ; several inches were gained between the sternum
and the chin ; yet there was an irregularity of the surface, a knotted
condition of the parts, very unsightly — at least so it would be con-
sidered in the female — here, however, it did not much matter, as a
cravat would conceal all. On the whole, considering the hideous
deformity of the child, I had reason to be well satisfied with the
result ; yet it did not at all merit the approval which the following
operation, and its consequences, elicit and demand: —
Case III. — Shocking Deformity after Burn — the Head Bound Down
to the Shoulder — Perfectly Cured, ivith scarcely a Trace of De-
formity, by a new Operation.
Mary M'N., aged 17, admitted into Mercer's Hospital, under my
care, June 18, 1860. The young woman was greatly deformed
from severe burn, wliich she sustained four years before. Her
parents stated that her clothes took fire, and were reduced to ashes
upon her neck ; all the skin upon its left side and behind was turned
Ml: l>i it in
black charred; and the shook irai 10 that her lit'*- i
despaired «>f for manj days; her head was affected too; and
dq this complication she escaped. Days and wrecks the Mark
slough \s ;l- separating and being cast off; and on several occasioni
she had b hard struggle for 1 1 1 V - However, after long confinement,
the part cicatrized, contraction going on, and ultimately to the
extent of connecting closely together the head and shoulder on the
affected side To be more particular, the condition of 1 1 1 * - patient,
on admission, was as follows: — The expression of the bee p.
most pitiable, though the features were handsome; yei the da
and months, and years of misery were stamped upon them, giving
the countenance the most painful east. The head and shoulder
reciprocated in their bondage, each being distorted hideously, the
former more from its symmetrical position — the head, afl it were,
being dragged down to the left shoulder, slowly, Bteadily, tena-
ciously, as far as the cervical spine could yield; then the uncom-
promising agent — contraction — still persistent, energetic, even against
gravity, brought up the entire shoulder from its normal position,
and approximated it to the more fixed part; the cicatrical tissue,
active in all this displacement, filling up the angle between the
shoulder and head, was most extensive and massive, attached above,
and expanded upon the mastoid process of the temporal bone,
and far behind for two-thirds of the transverse extent of the occipital
bone; wide and expanded, I say, here, at its upper attachments,
while from the mastoid process, in its course downwards to the
shoulder, its proportions were most dense, and firm, and resisting.
The base of the cicatrix, as it passed from the temporal bone to
the shoulder, was three inches and a half, while in thickness it varied
from an inch and a half to an inch and three quarters; it was dense,
fibrous, elastic as India rubber, not sensible to the touch, neither
discoloured by vascular supply, yet bands and spotted depressions,
whiter than the surrounding integument, dotted it throughout ; the
neck, by this rigid, powerful cord, was forced down to the left side
as low as the bones would permit ; and it was only by lifting the
shoulder, thrusting it up to the extreme, that the head could be
brought into a straight position, or into its vertical axis. Where the
cicatrix grasped the shoulder it did not terminate abruptly ; from it
numerous roots or claws spread out — some backwards over the
dorsum of the scapula, some over the superior attachment of the
deltoid — wliile the anterior margin of the trapezius seemed to
be incorporated in its structure: thus the whole mass was most
Mi:. Butcher's Report* in Operative Surgery. '.»
uncompromising in its character. The condition of the patient
previous to operation La most faithfully depicted in Plate I., Fig. 1,
In- the able hand of Mr. Forster, of Crow-street.
On the 20th of June I operated after the following manner: —
The young woman w;i> stretched on the operating table, and ren-
dered insensible by chloroform ; she was rolled gently orer on the
right side, bo as to render prominent the affected shoulder, and bring
up well to view the ueck and the vicious cicatrix throughout its
entire grasp. The parts being put upon the stretch, the knife
was first laid on the integuments over the acromial fibres of
the deltoid, about half an inch lower than this osseous point, and
carried downwards and backwards with a deep semicircular sweep,
and terminating behind and above the bifurcation of the spine of the
scapula; thus the knife travelled in a very curved manner, marking
out a flap fully two inches and a half below the expansion of the
central massive band of the cicatrix ; the most convex part of the
curve corresponded in shape to the arrangement of the modular
tissue, the same extent of sound skin being preserved all round ;
this flap was rapidly dissected up, great care being taken not to
bruise or injure it, lest its vitality should be impaired, and that
thus it might refuse the union or perish altogether ; its detachment
was with ease effected until the knife arrived at the matted down
disorganised structure, when the knife had to be used with more
decision, deeper, and with more force and freedom, at the same
time that the assistant who had charge of the head made greater
traction upon it towards the sound side, while a second assistant
depressed with more vigour the affected shoulder. By these opposed
forces deep passing bands were made to appear, and readily yield to
the edge of the knife. A long, cautious, I would say, protracted
dissection of those in-passing roots was required at the posterior
triangle of the neck ; and, to give some idea of the extent of the
detachment transversely, or from before backwards, it measured
somewhat more than four inches and a half. When this extensive
base, deep set and bound down in all directions, incorporated with
the fascia and involving tissue even beneath it, was set free, it was
gratifying to find how the head and shoulder permitted separation,
but yet not nearly enough. At this stage of the dissection the
parts stood thus : — The exterior flap of several inches was detached,
which, as the head was elevated and the shoulder depressed, slid up,
as it were, above the clavicle ; the healthy integument composing a
considerable part of this flap hung flaccid, while the cicatrical tissue
b> Mi; l>t n 111
i extensively at th<* rool of the neck, and incorporated with
tin- trapezius, having al tided, owing to detaohmenl and foi
for a considerable way, stood prominently out and resisted i
further advantages bj this method. Throughout this extensive
dissection ! >nt very little blood flowed— nothing that wai not easily
controlled.
I next had the flap carefully held up, and put upon the
stretch, and then rare fully introduced a Long Qarrow-bladed straight
bistoury through the massive cicatrical tissue at tin- base of the Hap,
and thrust it upwards suboutaneously, along the prominent band to
the summit of its temporal and occipital attachment. As the
instrument was forced upwards great precaution was used to present
it- point injuring the integument in this long track of from lour to
five inches; the instrument being introduced upon the flat, it
- now made to cut down freely from the integument the cicatrical
tissue by cautious gentle movements, This being extensively and
effectually done on the posterior Bide of the prominent ridge, the
edge of the bistoury was then turned anteriorly, and a similar
manipulation carried on. The edge of the instrument was next
turned directly backwards, and the cicatrical tissue -cored freely by
repeated incisions from before backward- and above downwards,
throughout its entire extent. To facilitate and render more guarded
ami certain the action of the bistoury the index finger of my left
hand, placed outside the integuments, followed it everywhere, and
made additional pressure where requisite; thus, from the consent of
action between the two hands, the incisions were perfected with as
much accuracy as if exposed to view. Again, as the bistoury
worked inside, the index finger of the left hand assisted t<> separate,
to press out, to unfold, as it were, this matted structure. The
result of all this subcutaneous proceeding was rendered manifest by
the relaxation and flattening of the vicious growth: and on the
bistourv being withdrawn the flap lay as flat upon the upper and
middle part of the neck as the healthy integument did at its base.
The operation was necessarily tedious ; yet, from the admirable way
in which the chloroform acted, the creature was unconscious as to
pain or suffering: when she had recovered from its influence, I
proceeded to dress the part ; and upon this proceeding I would wish
to be most explicit. In another place I have laid great stress upon
the rules which the surgeon should adopt towards saving the flap
from undue pressure, being handled or bruised: it should, in all
instances, be raised or made tense, as occasion may require, by the
Mi:. BUTCHER'S Report* in Operatire S/wyery. 11
application of forceps ; the instrument will only press or even wound
the merest point; it will not, as the fingers, compress it in extent,
arrest its circulation, and so threaten Its \itality This rule was
stringently oarried into effect in the present instance. The head was
gently inclined to the right shoulder, and steadied ao b j a few turns
of a bandage; compresses were softly applied over the detached
integuments and flap so as merely to sustain them in position, to
keep them in contact with the parts beneath ; and these, again,
retained by wide straps of adhesive plaster. I cannot be too im-
pressive here in Laying stress upon the way in which this extensive and
delicate flap was dealt with. Very little pressure would be sufficient to
rob it of its circulation, and so deprive it of accepting of the union
offered by the raw surface beneath; therefore it was sedulously
guarded against. The arm on the affected side was fastened to a
girth round the waist, which efficiently kept the shoulder down.
The raw surface from whence the healthy flap was dissected and
pushed up presented a wound of considerable magnitude, as large
nearly as the hand ; thin pledgets of lint, soaked in oil, were laid
all over it ; these again were covered with a few folds of old linen ;
and the entire supported by additional straps of sticking-plaster.
The patient was then conveyed to bed, and made to lie upon her
back, with her head resting on the same plane as her body. By
this arrangement there was no approximation of the head and
shoulders, and therefore no disturbance of the dressings. On looking
at the girl, as she lay in bed, no one could, for a moment, have sup-
posed that by operation the countenance could have undergone
so wonderful a change — so marked an improvement. But I shall
more particularly dwell upon this matter again. For several days
after this severe proceeding she suffered pain; but opium never
failed or lost its influence in restoring quiet or procuring repose.
For several days the stomach was upset, and the appetite
impaired, owing to the amount of chloroform inhaled, and the
restrictions as to position enjoined. Prussic acid, laurel water, and
ice, with sedative counter-irritation to the surface were efficient and
salutary agents. For days the restricting bands on the head and
arm remained untouched; and it was not until the fifth day the
dressings on the neck and shoulder were removed. To accomplish
this end every portion of the dressings were saturated with tepid
water, and the greatest gentleness used in their separation; the
adhesive straps readily yielded ; and each portion of lint over the
flap was gradually turned over, not directly raised, the fingers of
1 _ Mi: Hi 1 1 m i: - Report in (hh \tivt ry.
the left hand gentl) following, thus Bustaining the flap, and j
renting any interference with its newly-acquired cohesion
likewise, the oiled linl was readily removed from the ran lurf*
()u the part being full) exposed, it ith most gratifying e bow
lurately the flap remained in Its adjustment — how flat, regular,
and even the neck preferred its outline; no part whatever ihowed
an angry disposition. So the dressings were readjusted much ai
before, and after tlu- same fashion the greatest can- being tak
to guard against, and prevent the slightest movement of the head
or shoulder from that position in which tlu\ were both retained
from the first. Five days later the wound was again dressed;
similar precautions being adopted. And now it was apparent that
all that portion of the cicatrix which had been subcutaneously
detached, incised, folded OUt, was adherent in its new relations, and
had no tendency whatever to projection or starting out; on the
contrary, it took the shape impressed upon it at the time of opera-
tion, and retained it until the shed lymph and adhesions within
united it there. The exposed surface below presented a granulating
appearance; the dressings were put on in the same way as at first,
the straps of plaster only being laid on tighter.
During a period of three weeks but little alteration was made
in the mode of dressing; at the end of this time, union be-
tween the parts being so firmly contracted, and thus the life of
the flap secured, 1 guarded against a recurrence of irregularity
by the following procedure: — Having procured a quantity of
thinly-rolled lead, such as is used in packing tea, I folded up
several layers of it, and, by gentle manipulation, moulded it to the
side of the neck and shoulder, it lying in with great obedience to
e\ery inequality of the part; a thin layer of French wadding WU
interposed between it and the skin; broad straps of sticking-plaster,
12 to 16 inches long, brought from the back, and across the shoulder,
to the chest and neck, steadied it nicely in position. From day to
da\ these straps were carefully attended to, lest any undue force
might be exerted, and the part suffer from this even, steady, solid
pressure, and they were relaxed, tightened, or replaced, according
to circumstances. The inferior granulating surface showed a strong
disposition to throw out flaccid, languid granulations; an additional
piece of lead placed over it, thin folded little pledgets of lint being
interposed, exerted a most salutary influence on its repair. No
attempt was made to limit this sore by making traction on its edges;
on the contrary, all efforts tended towards having it healed by
Mk. Bi'tciikr's Reports in Operative Surgery. 13
replacement — by an extensive granulating surface fairly cicatrized;
every precaution was adopted, even in the application of straps to
support the compresses, so Hint the edges should not be drawn
together; for the centre of the strap was placed, as it were;, over
the centre of the wound, and then \t< ends carried, at the same time
and with the same degree of force, to the healthy integument on
either side. BO that the edges of the sore were rather pressed back
than otherwise.
The case altogether was seven months under treatment. Through
out this time the greatest caution was adopted relative to the
position of the head, the gentle steady support to the neck, the
topical applications, and mode of support to the granulating part;
and from the necessity of enforcing abundant reproduction of struc-
ture and ncwr skin, the healing was delayed, often stationary, and
only again restored to healthy action by the most painstaking and
careful dressing, steady strapping with adhesive plaster, gentle stimu-
lation by red precipitate, nitrate of silver, &c. ; and above all, I must
particularise a lotion which I have found more beneficial than any
other application, in life-giving properties, in these cases of languid
surfaces, flabby granulations, &c. The fluid consists of water, say,
eight ounces — tannic acid, a drachm — sulphate of zinc, a drachm —
small pieces of lint, folded into pledgets about the size of a half-
penny, should be soaked in this fluid, and laid evenly upon the
surface. A narrow marginal dressing of lint smeared with zinc
ointment being first laid on ; the entire should then be covered with
a piece of lint, spread over with the same salve ; and the whole
part supported by inch- wide straps of adhesive plaster — one made
to overlap the other, and afford the necessary support. This
dressing, I repeat, was most advantageous in this special instance,
and conduced, in a very remarkable way, to the restoration of so
extensive a surface without puckering or contraction.
It is 10 months since the young woman left the hospital cured,
and 1 7 since the operation ; yet there has been no disposition what-
ever to a recurrence of deformity — to projection of that cicatrical
tissue so cut up and folded out. My impression is, from a very
careful examination of the part, that it has been absorbed or removed
in a great degree. Be that as it may, the part shows no irregularity
or unevenness, though time sufficient has been allotted for such
changes, if they were likely to occur. A few days ago I had a
drawing of this young woman made by Mr. Foster, and engraved
by him. It is a most perfect resemblance in every way — (See
I [ Mi: lii urn portt 1.1
Plato 1 It- -2)\ and 1 think it is not too much to say -I
■ piii Fhere is n<» elevation whatever upon tin*
aeek, and no disfigurement, lave tin- little dotted white poi
which 1 have before alluded to as being produced by the intensity
of the applied heat. The hair, u- it is gracefully bound, cono
behind. Marking the large surface from which
the flap was dissected and Bhoved up, i> a more rascular condition
of the newly cicatrized part; but thi> ma) be entirely concealed by
a chemisette or high dress. The movements of this young girl's
neck are free, unrestrained, and graceful; while the left shoulder
holds its rightful position as contrasted with its fellow. This
restitution from deformity has likewise wrought B marvellous chan
upon the spirits, the aspirations, and the hopes of this young creature.
I may add, that 1 have recently performed, in private, an operation
almost similar to theonejnst detailed, and it promises to be in every
way at successful.
Resection and Removal of Bones. — In continuation of the Bubject
of resection and removal of bones, the following cases, 1 conceive,
afford many important [joints for consideration; and, moreover, they
are highly illustrative of the reparative efforts that may he looked
for, and surely depended on, in the earlier periods of life: —
Cask IV. — Death of the Shaft of the Femur from Fracture.
Protrusion of One End of the Dead Bone, with Shocking De-
formity. Extraction of Six Inches and a half of the Hone. Limb
/A itored to nearly its Full Length, and Consolidated by the
Application of " Butchers Spli/it."
Eliza C, aged 13 years, admitted September 26th, 18()0, into
Mercer's Hospital. Eight months before, she was thrown down by
a dray, and the wheel of this heavy waggon passed over the centre
of the left thigh bone, breaking it just below the lesser trochanter,
and at the same time inflicting the most severe bruising and con-
tusion; from the disruption of soft parts effusion set in so rapidly
that in a short time the limb exceeded in magnitude the sound one
by seven or eight inches, and from what I could learn, masked, to a
certain extent, the nature of the fracture. The girl was kept at
home and managed there, and the parents had the candour to admit
that the patient was most ungovernable, and did exactly what she
liked, so that no arrangements or directions made or given by the
Mb. Butcher's Reports in Operative Surgery. 15
gentleman who attended were either carried out or acted upon.
Soon the consequences of all this negleol became apparent, innam-
mation exceeded its proper bounds lbr the effusion of lymph and
the deposition of Callus J it attacked the periosteum and tin; hone.
detaching the one, and killing the other, these changes no doubt
being brought aboul more actively by the impressed violence at the
time of injury; the whole shaft of the thigh bone perished, and
nature made the effort for its extrusion by the formation of a large
abscess, corresponding to the original solution of continuity in the
bone, and steadily determining to the surface. Through all these
local changes the constitutional distress and excitement were
extreme, the patient passing through nights of watchfulness and
pain, distorting the limb on pillows, and changing it constantly
from one position to another in search of ease; at length the
abscess gave Avay on the upper and outer side of the limb, and
shortly after the upper end of the lower fragment of the thigh
bone appeared in the aperture, and once so, the contraction of the
muscles forced it out still more and more, all resistance to its
extremity being removed. Again, from the patient constantly
propping up the leg and knee with pillows in the hope of relieving
pain by relaxing parts, the shortening of the thigh was still further
favoured, until at length it lay absolutely on the abdomen with the
leg rigidly flexed upon the thigh. Her health was now so com-
pletely broken down, and her nights and days of misery so continuous
and prolonged, that she was brought to hospital and placed under
my care.
Nothing could present a more wretched aspect than the child,
the very life-springs seemed sapped by the long-continued irrita-
tion and withering fever. Emaciation of the whole body had
taken place in a most remarkable manner, and the face of this young
person had assumed all the contracted wrinkled characters of age,
except the eyes which were lustrous, projecting, and expressive of
watchfulness even to irritability ; the mouth too had characters of
distress, the angles somewhat retracted, lips thinned, white, and
tightened, with the teeth partially exposed and coated with a
yellowish paste ; the hair had considerably fallen out, and the skin
over the face, hands and chest, was moist and clammy, while that
over the abdomen and affected lower extremity was dry, i'urfuraccous,
and scaly ; the pulse was so rapid as scarcely to be counted, and it
wras weak and feeble, and even irregularly intermittent. And now
as to the condition of the limb — as I have said before, it lay drawn
16 Mi: P>i ri in 1: - Reports in 0\ ry
up upon the Abdomen, distorted in the most striking manner; not
only was the upptr fragment displaced in 1 1 1 1 - direction, but all that
below the solution of continuity was likewise drawn up, with the
upper end of the lower fragment thrust out, projecting two and a half
inches; thus the thigh was shortened, and curved here in a remark-
Able way, and l:i\ so closely on the abdomen that it WSJ only by
nK pressure tin- fingers were permitted between I > * * 1 1 ± surfaci
in like manner the leg, emaciated and powerless, lay rigidly upon the
posterior surface of the thigh, and could not by any gentle traction
be stirred from its long acquired position. After a long and pains-
taking investigation of the- case, 1 came to the determination to try
and save the Limb. The healthy state of the knee joint, the non-
implication of the hip joint, the integrity of the Leg and ankle,
conspired to make me adopt this view; yet, on the other hand, the
difficulties which seemed to surround the case appeared almost
insurmountable. The extraction of the dead hone, and that to -<>
great an extent as the probe indicated — the bringing of the power-
fully flexed upper fragment and knee from oft' the abdomen, and
restoring them in their original direction — the unbending of the
long flexed lei;- from the thigh — all this accomplished, the extension
of the Limb and its maintenance from retraction; and lastly, the all-
important question as to the compensative powers of nature in the
restitution of so extensive a portion of the osseous -tnu-ture, and the
adaptativeness <>{' the new material to the original design and
functions of the part.
On the day after admission, the child being placed under the
intiuenee of chloroform, the projecting dead bone, which was
partially loose, was grasped in the blades of a strong forceps, and
after some to and fro and partially circular movements, the concealed
end was started from its connexions and drawn out. It was now
confirmed that the shaft of the bone had perished for six inches and
a half in length; the preparation is in my possession, and depicted
in its full size in Plate III., Fig. 2; but a slight flow of blood
followed the removal of this extensive portion of bone, and 1 was
rather sorry to see the deficient vascular supply, lest it might be
indicative of the reproductive functions of the part being at fault,
for up to this time but little thickening was present, or deposition
of new material. On the removal of the support which this deadened
bone afforded to more than the lower two-thirds of the limb, the
curve and naccidity beeame still greater and more disheartening,
yet by gentle and continued force — the child under chloroform — I
I
y3
•■a
■
^
-.*■
*%
: v.
.•v.;
3
^
^
•
•
• •
W, Butcher on Excision of Bones and Joints
Mi:. Butcher's Reports in Operative Surgery. 17
drew it down Longer than before, and applied a well padded scored
splinl around it. I next commenced t<> bring down the limb from the
trunk, first being only able to insinuate a thin pad between it and
the abdomen, and likewise a thin one between the Leg and thigh:
from day to day I steadily increased the hulk of these in each position,
and had them, as space was gained, formed Into triangular wedge-
shaped supports, maintained and made more effective l>y the proper
pressure and support of bandages around the pelvis and the limb, in
a figure of eight form. When the Leg was brought a little beyond
a right angle, then a splint was laid behind the limb from the
tuberosities of the ischium above, to about the lower third of the Leer:
the limb was stretched upon this as far as it would yield, without
much pain, and all the space between it and the under surface of the
limb padded, so as nearly to fill the arch; a bandage was then care-
fully rolled from the foot upwards, and of course as it ascended, with
a moderate degree of tightness around the limb and splint; this
gently applied force tended to press the knee back, and thus
gradually to straighten the leg and thigh.
After considerable trouble and repetition of dressings, at the
end of about three weeks I had the limb sufficiently down to
apply my own splint : now the reparative material was becoming
abundant, and though it was moulded in a certain degree by the
restraint of the scored splint, yet it was apparent that a greater
force should be employed, and extension freely made and perma-
nently kept up. On the 20th of October I applied my own
splint; having first drawn down the limb by long, steady, and
powerful traction, kept up for nearly twenty minutes. An assis-
tant fixing the pelvis and upper fragment, I clasped the knee
with both hands and steadily drew it in an opposite direction
downwards, thus greatly elongating the thigh, and bringing it
to within two inches of the length of the sound one; a second
assistant then took my place, and kept up this extension, while I
adjusted the long splint ; a well padded yet narrow lac was placed
along the descending ramus of the pubis and that of the ischium,
the ends brought up behind and before, a layer of French wadding-
being interposed ; the long splint was then laid along the outside of
the limb, properly padded, and the foot fastened to it below ; the ends
of the counter extending lac were then brought through the holes
of the splint which reached to the arm-pit, and tightly tied. Thus
the limb was maintained at the extreme point of extension
that it could bear, and, as it was necessary to support it behind,
VOL. XXXIII., NO. 65, N. s. c
18 M 1: Hi k ii i
in order to bring in ;m additional i i splint wafl laid al
mrface, and the concave ipaee between it and the
limb rillcM I with lofl pads; then a roller wtu& applied from th<-
ankle upwards, lashing the leg to the long splint, and, tended
the knee, supporting in its turn- the posterior splint, and
pressing the knee backwards, and thus -till inure tending to
aighten it. Bo on, the roller was continued up to the groin, and
then made to pas- aCTOSB the pelvifl and the upper part of the Long
splint, in a figure of eight form, and SO maintaining it to the trunk
and thus securing the limb in a Btraight line. Some gimple dressing
was laid over the ulcerated opening, from which escaped a fery
trifling quantity of healthy pus.
After a fortnight's application of the splint in this way, the
limb became perfectly straight, the knee on a level with the
sound one. I need scarcely mention that, during all this time
of trial, the little patient was exceedingly intolerant of treat-
ment, yet, l>y management she was compelled to submit, all due
caution being observed to mitigate her Bufferings in every way;
indeed she was forced to admit she did not suffer nearly the pain
that she endured before she came to hospital ; independent of her
statements altogether, her improved appearance bore testimony to
the fact. No doubt suitable food, stimulants, and opium, in abun-
dance, were administered with a free hand, and conduced to this end.
Her sleep returned and appetite sharpened, blood was abundantly
made and healthily appropriated to the restitution of tissues, and
the languid and debilitated frame was strengthened, and nervous
energy invigorated. Thus these important changes were brought
about by the most assiduous care, within a period of three months.
The bringing down of the limb, the straightening gradually of it,
was a trying ami wearisome process, I admit, yet I could not for a
moment warrant any more expeditions or violent mode. It might
be presumed, if the patient was placed under chloroform and rendered
insensible, the thing might be done at once. Well, I apprehend, if
it had been so dealt with, the disruption of parts that could not so
suddenly or readily yield would have led to the formation of
abscesses, precursored by active and wide-spread Inflammation with
its concomitant train of additional evil disturbances.
January 1, 1861. The report goes on to state that the girl had
lost all her characteristic delicacy, that she had become fat and robust
— that the reparative material effused, though deposited slowly at
first, yet was then in abundant quantity, not only filling up the
Mr. Butcher's Report* in Operative Surgery. L9
extensive i_r; i ] > between the upper and lower ends of the thigh hone,
hut Likewise sufficiently massive is its diameter; and it was becoming
firmer everyday. During all this time permanent extension vrai
guardedly kepi up, and the limb wa> only two inches shorter than
its fellow, and it was maintained throughout in its proper axis — the
transverse piece of wood upon which the splint re<t< preventing
inversion or aversion, Towards the end of the month the uniting
medium was perfectly solid and unyielding; and on the 1st of
February she was dismissed cured. I have seen her since then, on
several occasions, and the power of the limb and its movements have
steadily increased. Nine months have now passed over since she
left the hospital — she came specially at my request, in order that I
might have a drawing made; the drawing and the engraving have
been executed by Mr. Forster, of Crow-street, whose name is a
sufficient guarantee for its faithfulness and execution. (See Plate
III., Fig. 1.) Her condition now is as follows: — she is strong,
healthy, and robust; as she stands at rest no one would suppose
that there was anything amiss with her; on the most accurate
measurements her left thigh is scarcely two inches shorter than the
right, and a boot raised with cork on the inside so perfectly com-
pensates for the deficiency, that it is scarcely perceived; she has
only a slight halt in Avalking, the functions of the hip and knee
joints being entirely restored. The case, in all its bearings, presents
to my mind as many important points for reflective study as any on
record, while the practical deductions flowing from it cannot be
over-estimated.
Case V. — Extensive Caries of the Upper and Lower End of the
Tibia; Excision and Gouging out of the Diseased Bone; Perfect
Recovery, with the Functions of the Knee and Ankle Joints
Preserved.
Eliza Martin, a fair-haired girl, aged 10 ; admitted to Mercer's
Hospital, February 12, 1861. She was reduced to the lowest state
from long-continued disease of the left tibia. Above and below, the
bone was affected. So apparently incurable did the case appear,
and so emaciated and depressed the patient, that amputation of the
limb had on several occasions been proposed, previous to her being
put under my care. On the above date she was in the last stage of
hectic; she was thinned and worn out from profuse colliquative
sweats, with alternating diarrhoea ; her sleep was unrefreshing, and
c 2
Mi: BUTCH!
nights absent till the approach of morning Appetite capricious
ami \n\ -mull ; and t lit- pi of nutritive assimilation altogether
subverted. The puke was rapid, feeble, and email; and there
general irritability about the child painful to witness. The nervous
tnptorm assumed a very definitive character. For several w»<
before the child's admission she ivaa attacked l>v chorea; and this
idition maintained in the most aggravated form, even in con«
junction with the characterized fever that I have just alluded
The history of the case pointed to the tacts — ofinjurj sustained from
falling down a ladder producing violent inflammation over the
tibia, above and below, and its extreme ends, save the articulating
surfaces — of injury inflicted where the leuco-phlegmatic temperament
predominated, when, after the subsidence of acute inflammatory
action, a low, mischievous, disintegrating action was Bel up in the
stricken parts, terminating in abscess of the soft part- covering the
bone-, and caries of their structure. From this local injury, extensive
both above and below, the constitutional symptoms alluded to were
evoked. The constitutional and local symptoms were each BO
developed in their way that amputation seemed not an unreasonable
proposal. Vet, from the BUCCessee which I had obtained, in almosi
similar cases, by excision, I determined on cutting out the diseased
bone in each position, and straining every effort to save the limb.
February 20th. — The girl was placed on the operating table, and
rendered insensible by the administration of chloroform. The limb
being steadied above and below, I made an incision about four
inches in extent along the anterior and inner surface of the expanded
head of the tibia, through the ulcerated soft parts; their integuments
were freely dissected from on the bone, revealing a very large
extent of it softened, discoloured, some broken up, and carious;
the compact layer in front being decayed. The point of a fine
Luer'e saw was introduced, and made to cut effectively, so as to gi\ <•
full room for manipulation with the gouge; nothing could answer
the purpose better than this instrument. Great care was taken not
to interfere with the upper articular surface of the bone, many
layers beneath it being fortunately healthy. From this point down-
wards, about three inches of the cancellated texture of the bone
together with its anterior and lateral walls, were freely and cautiously
removed, while the posterior wall, with a stratum of the cancellated
tissue, being healthy, were suffered to remain, and so maintain the
integrity and continuity of the bone. I next proceeded, in a like
manner, to deal with the lower end, but had to contend with a little
Mi:. Butcher's Reports in Operative Surgery, 2]
more difficulty. The wall of the bone herewas not softened to the same
extent as that above, though the disintegration internally was nearly
to as great an extent. Examination with the probe, through tin; small
aperture that Led i<> the interior, confirmed this new; an abundant
supply of sanious pus persistently welled up and flowed over from
it. The internments being divided to about three inches in extent,
the hone was freely laid hare on its anterior and inner surface, and
immediately over the ankle. The crown of a trephine was applied,
and an opening being freely made with a fine saw, the aperture was
increased, and so the carious cancellated tissue gouged out to nearly
two inches in extent. The same watchfulness was had in requisi-
tion here, as above, not to impinge on the articular surface of the
bone. The entire disorganised part being taken away, the cavities,
both above and below, were filled with long slips of lint soaked in
oil, and pressed down firmly into every recess; a mode of dressing
which was perfectly effectual in stopping hemorrhage, giving due
support, and stimulating, by its presence, healthy action. The limb
was then carefully rolled, and, as the bandage passed up, an
additional compress placed over the wounds so as to retain steadily
the internal adjustment; next, the limb was placed on a padded
splint, extending upwards nearly to the buttock, and retained
immovably by a bandage, so as to prevent any flexion of the knee
joint.
During the time necessary for this severe operation the child
was kept under the influence of chloroform; and, on this agent
being discontinued, she quickly awakened to consciousness, and
quite unaware of what had been done. Very trifling fever followed
the operation ; all irritation was subdued by opium ; I have no fear
of it, even in children. Five days were allowed to pass over before
the wounds were dressed ; the lint was easily removed, as already
healthy pus began to be secreted from each cavity. It was interesting
to observe how, day after day, accessions of granulations were added,
and tone was imparted to their growth by the gentle pressure of the
lint, compresses, and bandage. A fortnight had not elapsed when
the beneficial effects of the operation were becoming evident; the
sweats ceased, and the diarrhoea disappeared ; the pulse came down
many beats, and the sleep returned; food was eagerly sought for,
and healthily assimilated ; and, at the end of the third week, the
chorea had disappeared. I must state here that tonics, zinc, iron,
&c, were administered; but I cannot separate, in my own mind, her
altered state — her rapidly mended condition, from the soothing
Ml; lil 1- ''J
effects produced bj an operation thai at once took away tin- prfani
iiVl. M>uroe of irritation and debility, Month- the
ehild'a health irafl improved; and gradually the granulations filled
up tin- basms out out, and ultimately assumed ■ firm, den
and osseous character, competent to take the office of that which th
replaced. A month lince, the child I* -ft the hospital perfectly cured
A long time irai requisite to repair the shattered health— the rotten
hone. Operative surgery', in feet, did for both what medicine could
never achieve what the vis medicatrix naturm was incompetent to
effect. As tin- horn- was repaired bo was all swelling dispersed, both
in the limb and eontiguoua joints; quicklj the knee and ankle
regained their motions, their perfect movements; and, as the repaired
shaft of the hone was restored to solidity, BO did it bear with
impunity the weight of the body, and the Bhooks transmitted through
it in progression. This young girl, that was certainly doomed to
be mutilated for life by amputation, is now running about with her
playfellows, rescued from deformity by a better mode of treatment —
resection.
Cask VI. — Complicated Amputation of the Leg, to save the Knee
Joint, demanding Ligature of the Popliteal Artery as a Secondary
Proceeding; Pyemia Successfully Treated by Mercury and Stimu-
lants. Recovery.
EL 11., aged 17 years, admitted to Mercers Hospital December
31, 1860. in childhood she had been a miserable martyr to scrofula,
which, after marking the neck, arms, and some parts of the trunk,
remained in abeyance for a few years — however, for the last eight
•rs she has been a constant sufferer. The soft parts in the ham,
back of the thigh, and calf of the leg were attacked with scrofulous
deposits throughout, running into deep and extensive ulcerations,
followed by rigid cicatrices contracting the leg upon the thigh at an
obtuse angle, and permanently maintaining it so. After long and
weary confinement these parts were healed in this deformed way;
Scarcely were they so when the same disease attacked the soft parts
and bones of the tarsus, toes, and ankle joint of the same limb;
wide-spread ulcerations and caries at length settled in the part. At
times nature seemed to make an effort at repair, but in a few hours
all improvement woidd be swept away. After repeated and fruitless
attempts through a long succession of time — eight years — no per-
manent improvement could be produced, or any change, to be relied
Mi;. Butcher's RtporU m Operative Surgery. 33
on. eifeeted ; and so her health gradually gave way. and her Btrengl 1)
declined under wasting fever. When she came under my care, the
Umb was a deformed shapeless mass, totally spoiled in its pro-
portions and integral pwrt*. The leg waa confliderably flexed on
the thigh and fixed so, all the integuments covering the call' and its
muscular structure were deeply pitted and matted together; while
the soft parts and hones of the foot assumed a most slnpele.-s ma — .
three to four times it- normal size, extensively ulcerated, pouring out
copious foetid discharge, and accompanied always with pain, hut of an
intolerable character when the patient moved about in the erect
position with the limb dependent. The young woman supplicated
for its removal, and indeed there was no prospect of relief by any
milder method; to save the knee joint was an all-important con-
sideration, and to effect this object I planned an operation somewhat
similar to that which I have described at the end of my Second
A I emoir on Excision of the Knee Joint.a The patient being carefully
managed for about a month after her admission to hospital ; on the 1st
of February I operated in the following way : — The patient was placed
on the operating table and brought under the influence of chloroform,
and the femoral artery commanded at the groin. Standing on the
right side of the patient I cut out a long flap from the anterior
surface of the leg, and fully two-thirds of its length; this was
rapidly dissected up and maintained by an assistant. I then trans-
fixed the only healthy part of the calf from its outer side, and cut it
free ; I next carried the blade of the amputating knife along the
outer side of the cicatrix in the thigh to its highest attachment,
then along its inner side in a similar manner ; the incisions, from
the obliquity given to the knife, cut out the cicatrix in a wedge-
shaped form, the base externally; this being detached, the bones
were freed from the soft parts and sawn across, with a slight curve
in front, about two inches below the articulation ; numerous arteries
spouted, seven or eight considerable vessels were tied, besides the
posterior tibial and fibular arteries, which were cut very high up —
immediately after then* origin ; this could not be avoided as the vessels
were incorporated with the back of the cicatrix. The flap was now
closed, and the patient allowed to rest for some minutes after revival
from the chloroform. Just after being removed from the operating
theatre arterial blood gushed out from the stump ; fortunately I was
beside the patient as she was carried away, and at once grasped the
* Dublin Quarterly Journal, February, 1857.
•_' I Ml; BUTCH! ' ' ///
part, ami had her brought back t<» the operating table An assistant
made pressure on the femoral artery at the groin with tin- end of ■
covered with flannel, before I relaxed mj erteadj gripe irhich
eommanded the vessel 1 found that, owing to the causes necessita-
ting the ligature of the posterior tibial arterj bo close to tin- main
trunk, and m>t haying probably sufficient hold, it was forced off
during the movement of the patient by the impulsive current from
above. 1 made a vertical incision over the popliteal artery, ami
ligatured it at the angle of flexure, carefully liberating it from the
vein with which its connexion was very intimate. After this pro-
ceeding the patient was removed t<» bed, the thigh elevated, the
Stump evenly BUpported, and the long anterior flap -lightly curved
backwards ami re-ted on the pillow; thus the entire was left t<»
glaze. Wine and opium were administered rather freely, as the pulse
was laboured and shabby.
At ') o'clock, P.M., five hours after the operation, I proceeded
to dress the stump, the patient being again placed under the in-
fluence of chloroform. I first connected the external and somewhat
posterior short flap, through the entire of its extent, about three
inches, with the outer side of the anterior long one, by several points
of wire BUture; I then folded the long anterior flap over the curved
ends of the bones and up along the posterior surfaee of the thigh,
it fitting admirably into the deep sulcus from which the cicatrix
was cut out. Numerous points of the wire suture were employed
to retain it in accurate position; by the turning back of the long
anterior flap in this manner it will be understood how it had, as it
were, contained in its curve on the outer side, the short external and
posterior one, so that the short Hap was stitched to it throughout its
entire circumference at isolated points. Nothing could be more
accurate than the adaptation of these parts ; each fitted admirably
to the other. In order to give additional support, long compresses
were laid over the flap in the axis of the limb, steadied by longer
straps of adhesive plaster in the same direction, and a few turns of
a roller very gently, merely retentive — the object being to guard
against the flap drooping, and, on the other hand, not to interrupt
its vitalizing supply; the ligatures were brought out at the internal
angle of the wound. The stump was then placed on pillows, but
not much elevated, the object being that no additional difficulties
should be added to the extensive flap getting its arterial support ; the
unforeseen event, the ligature of the popliteal depriving the part, to a
certain extent, of that free anastomosis that was considerably estimated
Mi:. Butcher's Reports in Operative Surgery. 25
and greatly relied upon for fa maintenance, Immediately after, a
full opiate was administered, and repeated at intervals during the
day.
Everything went on moel favourably up to the 5th, when I re-
moved the dressings, the edges of the wound had united perfectly in
many parts; at the extreme end of the Hap that turned up into the
angle on the thigh, it was dark for about a quarter of an inch, and
evidently its life was gone; everywhere else the flap was steadied,
and, for the most part, solidified in its position ; I reapplied dressings,
actuated by the principles just detailed, and ordered a moderate quan-
tit v of wine, nutritious diet, &c. Without any apparently assignable
reason, on the 9th, a remarkable change was ushered in — great
prostration and uneasiness referred to the chest, with a rapid small
pulse ; I at once raised up the patient, conceiving those symptoms
might have arisen from pulmonary engorgement, occasioned by the
somewhat doubled up position that the patient had lain in from the
time of the operation. At a later period of the day utter prostration,
and I feared pyemia was set in ; on stripping the stump the extreme
end of the flap was being separated by a deep ulcerated line, else-
where the edges of the wound were coated with a yellowish,
unhealthy deposit. The wound was dressed with lint steeped in
turpentine, long strips of linen, wetted in warm water, were applied
as adhesive straps to support the flap, the end of which refused
union; this mode afforded a very efficient means. Over all was
placed a thin linseed meal poultice, made with chloride of soda
solution and water (one drachm to the ounce), over this a piece of
oiled silk, the entire retained by rollers, and the part supported on
a pillow — ordered six ounces of wine, a full turpentine enema to act
on the confined bowels, and a draught with ten drops of turpentine,
tincture of cardamoms, &c. ; also placed patient on small doses of mer-
cury— two grains of calomel and quarter of a grain of opium every
third hour. 1 1 P.M. — Pain very much diminished ; bowels well freed ;
wine and beef tea. February 10th — Much in same state; slight
lurking pain in lower part of right chest ; wound not much altered
in character, and dressed as on yesterday; to continue the pills;
blistered over the seat of pain; pulse so shabby, wine to be
increased to 10 ounces through the day, and 6 for night. On the
11th no improvement; respiration more difficult, ala? nasi expanded
during each effort; cannot make a full inspiration, pain so sharp;
purulent smell from breath quite perceptible ; lips livid ; pulse so
rapid as scarcely to be numbered ; great prostration, lividity, and
M i; lii I ( ii i 1 1 -./<•/•'/
mi. a. in, . •; hut Little change in the •round; ordered I
imn- draughts, and, to alia) the constant cough of urritati
prussic cu-iil iiml morphia a large blister over the sternum— -10
ouj i wine l»\ day, and 6 at night - quarts of beef t
ami tlu- calomel to be continued* (hi the 1-th the report itates: —
She had some sleep ; pulse nol bo rapid; respiration not so embar^
; pain in obesl less, but cannot take in ■ full inspiration ,
stopped by acute pain: however, on the whole, this symptom ii
better than on yesterday; purulent foetor intolerable from the
breath; no pain in the wound; stump dressed as before; the
patient lies on her hack still and quiet like a log, bo little eviden
of vitality about her; however Bhe swallows all her nutriment — 10
ounces of wine, beaten up with spirits and warm milk, i
quarts of heel' tea, 8 ounces of wine for night ; calomel and opium
to be continued. 13th. — Her respiration somewhat improved;
purulent expectoration in quantities, ahe nasi not now dilating, yet
deep inspiration as yet perfectly impracticable, Has consumed all
the nutriment and wine given to her, without the slightest >ickn
of stomach; the wound looks healthy; dressed as before; changed
the patient to a fresh bed, propped her up with pillows, to relieve
the congested lungs, for a couple of hours at a tune; bowels well
freed; calomel and opium continued, with a full opiate at night J
ordered 16 ounces of wine, '1 quarts of beef tea, an egg with
boiled milk, and 2 ounces of spirit twice in the day and night.
14th. — But little change; to continue everything; expectoration of
purulent matter still abundant, and breath loaded with its lector.
15th. — There is a remarkable change in the pulse for the better, its
beat is more determined, and not hurried in a current, yet still very
rapid; the pain has left the right chest altogether, but still lurks
beneath the sternum, and deep in the left lung; respiration still
hurried and >hort ; mercurial diarrluea, so -topped the pills; placed
'J drachms of mercurial ointment in each arm-pit, and gave 40
drops of laudanum night and morning; to continue lb' ounces of
wine, 4 ounces of spirit, eggs and beef tea as before.
The patient continued much in the same state, depressed and sunken,
until the 21st, when there was a marked improvement — the pulse
coming down several beats; the respiration more developed and not
so rapid ; the absence of pain ; the changed aspect of the countenance
from its leaden lifeless colour ; the restored movements of the eyes
from then* settled stare. In conjunction with this altered consti-
tutional manifestation, there was a corresponding local change : the
Mi; Butcher's Reports in operative Surgery. 27
little deadened margin of the flap was entirely cast, oft", healthy
granulations had sprung up t<> compensate for it. The ligatures
were unusually delayed— nol being cast off until the 22nd; the
separation of the cord from the main artery I looked forward to, not
without apprehension; however, the firsi few days of repose and
quiet efficiently sealed the vessel. The patient gradually and
steadily progressed until the 27th, when a large depot of matter
formed near the buttock. I had to cut very deep for it, and
certainly not less than a pint of matter escaped. A few days later
T had to open another near the crest of the ilium, when about eight
ounces flowed off; the stump was entirely healed at this time, and
the patient was confined to bed solely for the management of those
extensive abscesses by the careful adjustment of pads and bandages;
diminishing gradually the pressure from the circumference to the
centre of each, and having the incision open for the escape of pus
as fast as secreted, these became gradually obliterated. During the
latter part of the management of this case, the large quantities of
wine and spirits were, of course, dispensed with, but a very nutritious
regimen was even still adhered to. At the end of March she was
perfectly well ; the stump was admirably formed ; the long, trans-
planted flap lay well up in its berth behind, covering the ends of
the bones in a most perfect way, without strain or tension ; a few
days later and the young woman was quite happy, moving about
freely with a wooden leg.
It is unnecessary to go back upon or to recapitulate the several
points of interest contained in this case — there are many in a practical
way that cannot be surpassed ; there is one, however, that I must,
before concluding, specially allude to ; I refer to the treatment of
pyemia by the abundant exhibition of stimulants, and the free
administration of mercury and opium. In several instances, some
of which have been published in these reports, I have been fortunate
enough, by this mode of treatment, to rescue the patient from the
very jaws of death, and the present case adds another to the list.
I do not think this is the place to canvass the various opinions of
Pathologists as to the nature of the affection, and the theories in
support of their views, but I do with confidence affirm, that the
practical lesson — the aphorism which I have laid down — will not be
found deficient in efficacy or unproductive of good.
}8 M B M M KAMA]
Am 11 Observations on Ep\ Bj Rawdon MachajcjULa,
\1 i; i \ Professor of Materia Medka, 1( ( S.I., and one «<t' the
Surgeons of the Meath Hospital, vVr
l u Lesions are popularly considered <>f grayer import than
hemorrhages, no matter what their seat; yet of all these, t<> none
i^ less importance in general estimation attached than to that
which makes its exit through the QOStrils; and why this BUOuld be
can only be explained on the two-told ground of ii^ extreme
frequency and of ignorance. People so repeatedly witness a bleeding
from the nose unattended with any evident BerioUS Consequence, tin-
public generally are bo much in the habit of attributing the same
effect to the Bame cause, that it is not to be wondered at that 90
everv-day an occurrence should give rise to but little alarm, and it
is only when the loss of blood becomes serious as to its amount,
and difficult in its being checked, that any importance is attached
to what must, or at all events should, give rise to anxious con-
sideration on the part of the reflecting physician. Numbers of
people Buffer from repeated attacks of epistaxis, of a more or less
grave character, who never think of consulting a medical man on
the subject; and it is only when an attack more obstinate than
usual occurs that the surgeon is sent for, and but too frequently
every resource of his art has to be put in force ere the hemorrhage
be arrested, and the safety of his patient secured. Nor, in my
mind, are we ourselves sufficiently free from censure in this respect.
To many an attack of epistaxis is but an attack of epistaxis, to be
combated by the one routine plan of treatment — its exciting cause
i- not investigated with sufficient care; our every energy is directed
to arresting the flow of blood, without that due weighing of the
exciting cause that the nature of the case so imperatively demands;
ami we hasten to apply our styptics, &C., to control that hemorrhage,
which, after all, may prove to have been but a salutary effort of
nature. Nor is this so much to be wondered at, when one for a
moment reflects on the scene that but too frequently presents itself
on the surgeon's arrival; basins apparently filled — cloths saturated
with blood — anxious relatives and friends surrounding, and officiously
but ineffectually tendering relief to the patient, scared at what, to
the non-surgical eye, must appear a serious loss of blood. On the
moment of his arrival the surgeon is besieged with entreaties to
afford that relief without which dissolution appears imminent;
Mil. Macnamaka on Epiitaais. 29
everything conspires to render hurried that decision which should
be calm, and founded on a rational considcrat ion of the nature of
the ease, based on a oorred diagnosis of the cause of the hemorrhage ;
without which future serious injury to the patient mav OCCUT, and
on the correct establishment of which, ninch more than the present
apparently successful treatment of the case may depend; impressed
with the importance of these considerations, therefore, is it that I
Venture to put on record the result of much observation and con-
sideration of a lesion, that, in my mind, is of grave moment.
The ii rst and most important consideration for us to entertain is,
whether the popular opinion be correct, and whether that in every
case, a bleeding from the nose is but a bleeding from the nose, to be
looked on as haying but the one source or origin, and to be treated
but on the one plan. That such opinion is founded on very crude
notions, far removed from our advanced stage of etiological and
pathological knowledge, is but too evident to every one who merits
the name of physician or surgeon ; yet some advantage may accrue
from a glance at these causes, and a retrospect of what has been
written by the great fathers of our art ; so that I shall not apologise
for pressing their labours into my service, and subsequently adding
thereto any trifling information in my power to place at the disposal
of my professional brethren.
In limine, I may be permitted to observe, that every case of
epistaxis may, in my opinion, be reduced under one or other of two
great classes — the Sthenic or the Asthenic. No matter what be its
cause, whether accidental, critical, or idiopathic, it must be answer-
able to one or other of these two great classes, and, as it belongs to
one or other of them will its treatment vary, and be successful, or
the reverse ; and I cannot sufficiently express, in my opinion, the
importance of the practitioner, called on to treat such a case,
deciding, in his own mind, to which of these two classes the case
in question may belong: to the patient will this decision be all
important, and to the practitioner, in so far as his reputation is
involved in the successful treatment of the case on scientific and
sure grounds, is such correct solution of the question, if not on
higher and more conscientious grounds, also of equal importance.
The exciting causes of epistaxis may be reduced under two great
heads, viz.: — external and internal: amongst the former mav be
ranked all injuries or violence applied to the nostrils, or in their
vicinity — such as blows or wounds of greater or lesser importance,
from the slighter box, to that which is attended with fracture of the
Ill M LCNAMABA ( I
il bonee; the v\ iiUi.Mi of polypi i caries: of the bonei of the doi
the introduction into tin* nasal ftnTrtifff trf irritant Mil nd
i bodies, whether in the form of solids, fluids, or vapora
riolenl sneezing. Undue increase of temperature, whether solar or
artificial, directed on the head, by predisposing to afflux of blood to
tin* head, ives rise to epistaxis; for instance, the direct action
of the sun'i pays on the uncovered head, or on it when protected
with black ooyerings or metallic head pieces, Lb ;i not onfrequeni
iree of epistaxis ; the exposure of the head to rays of heat radiating
from i Bra, Bitting in an ill-ventilated room, lighted from above by
i, favours cerebral congestion, frequently followed by epistaxis
Of all these external exciting causes of epistaxis, each of my read
must be able to furnish for himself many examples. [, myself,
have Been a very obstinate bleeding from the nose produced in a
young Bchool-boy by the forcible introduction into the nostril of ■
piece of slate pencil; in another ease, the incautious inhalation of
the vapours of strong caustic water of ammonia was followed by a
sudden and violent gush of blood from the nostril, most difficult to
arrest ; and in some cases I have, to my own satisfaction, been enabled
to trace a frequently recurring epistaxis to the patient's habit of using
Cork snuff; whilst every school-boy's experience furnishes him
with many examples of "bloody noses/' resulting from well planted
blows on that organ.
It is with the internal causes of epistaxis, however, that the
division into sthenic and asthenic is principally concerned, and tli
have well been classified by ,1. P. Frank, in his masterly treatise —
Di Curandis Ilominum Marin's — into those which increase the flow
of blood to the head, and those which impede its return from it.
M Qurv eel motum sanguinis ad caput auyent, net eruoru regressum
prapediiuit." Amongst the former of these may be ranked inflam-
matory diseases, erysipelas, small-pox, measles (" prc-eniinentlii,"
writes Frank), catarrh, violent anger, protracted and severe head-
aches, cerebral congestion, dependent positions of the head, violent
muscular exercises, severe vomiting, alcoholic excesses, protracted
-watchfulness; and, amongst the latter, mental emotions, accom-
panied either with profound terror, or excess of modesty , deep sighing,
great anxiety, grief; as also shouting, speaking for a long time,
excessive laughter, crying, singing, playing on wind instruments.
great straining of any kind, tits of coughing, dyspnoea, cardiac,
pulmonic, hepatic, splenic or renal disease, congestion of any of the
abdominal viscera, over distention of the stomach or intestines
Mk. Mac \\m\i:\ on Epit taxis. 3]
whether with food, Mains, OT fvBCft] nutters, ascites, the gravid uterus,
pressure on any of the Large reins by tumours of ■ BCfofolovs.
malignant, or other type, intestinal worm-, especially ascaridesj con-
vulsions, particularly of an epileptic character, cold. Long continued
and applied to the extremities, constrained positions of the body,
ill-fitting garments producing irregular pressure, tight lacing, sup-
pression of the menstrua] secretion, or of BO habitual hemor-
rhoidal discharge. Also such diseases as have a tendency to produce
I BpanemiC condition of the blood; for instance, typhoid and ady-
namic fevers, scurvy. Long exposure of the body to the influence of
water, as in fishing, or protracted immersion, or long continued
exposure to lain, resulting in that condition named by Huxham,
acute scorbutus, in which, generally superadded to hemorrhage
from other situations, we meet with cpistaxis of a most formidable
character) and most difficult to control. A state of blood somewhat
similar is induced by the too long continued use of alkaline, as also
(but in a minor degree, and from quite a different cause), of acid
remedies. In Huxham's Essay on Fevers, we find a most interesting
case, where hemorrhage from the mucous surfaces, dependent on
this condition of the blood, ensued from long continued excessive
doses of the sesquicarbonate of ammonia. This case is so instructive
that I am tempted to quote it : —
" I had lately under my care a gentleman of fortune and family,
who so habituated himself to the use of vast quantities of the
volatile salts, that ladies commonly smell to, that at length he would
eat them in a very astonishing manner, as other people eat sugared
carraway seeds. — A Api/uvQaytia with a vengeance ! — The conse-
quence soon was, that he brought on a hectic fever, vast hemor-
rhages from the intestines, nose, and gums, every one of his teeth
dropped out, and he could eat nothing solid ; he wasted vastly in
his flesh, and his muscles became as soft and flabby as those of a
new-born infant ; and broke out all over his body in pustules, which
itched most intolerably, so that he scratched himself continually,
and tore his skin with his nails in a very shocking manner; his
urine was always excessively high coloured, turbid, and very foetid.
He was at last, with great difficulty, persuaded to leave this per-
nicious custom, but he had so effectually ruined his constitution,
that, though he rubbed on in a very miserable manner for several
months, he died tabid, and in the highest degree of a marasmus ; —
and I am persuaded) he would have died much sooner, had he not
constantly drank very freely of the most fine and generous wines,
Mi: M a . \ id \i: \ on A)"
and dull used ' quantities of milk, and antiscorbutic
juices well acidulated with juice of Seville orange*, lemons, &
It ma\ qoI be ami— to extract from my note book a i'*\v cases in
which the epistazifl was due to one or other of these causes; and
the firBt that I shall submit Lb that of M.l>., a girl, aged 18
admitted December, 1861, into Meath Hospital, under lh-. Stok<
care, Buffering under symmetric erysipelas of the face. I was con-
sulted about this girl the evening before, and she presented high
febrile symptoms, and stated that her complaint was ushered in with
general bronchial symptoms, flushing of the face, rigors, headache!
Loss of appetite, and that, on the previous evening, she Buffered from
a -mart attack of epistaziS, which, with difficulty, was controlled,
and not until -lie had lost a considerable quantity of blood from the
not*, a statement rally confirmed by the coagula that still plugged
up the Dares. 1 sent her into hospital that evening, and next
morning the invasion of erysipelas was of a well-marked type. The
further record of the case would he foreign to the object of this
paper, hut I may be permitted to observe, that the quantity of
blood that she lost on this occasion was fully evidenced by her
pulse, the character of which earl) called for the administration of
wine.
The effect of violent anger in producing epistaxis is well exhibited
in the following case: — Some years since 1 was summoned in all
haste to attend a young gentleman in Lceson-street, under the
following circumstances: — His father had found it necessary to
remonstrate with him on some portion of his conduct that was dis-
pleasing to him, and, in the course of the altercation that ensued,
struck him a few light blows — light, but, I believe, the first that
this young gentleman had ever received; the effect produced was
such as to alarm the whole family — his face Hushed 14), and became
of a mahogany hue, his eyes became blood-shot, the veins in his
neck and temples stood out as whipcord, he foamed at the mouth,
became inarticulate with rage, and, in fact, assumed all the appear-
ance of one about to have an apoplectic seizure ; on my arrival I
found him in this most alarming state, but before I could take any
measures for his relief, a gush of blood took place from the nostrils,
which, instead of checking, I need scarcely say I encouraged; and
after a considerable quantity of blood was lost, he fell into a profound
sleep, accompanied with much stertorous breathing, and, on my visit
next morning, was as if nothing had ever happened.
I had recently under my care in the Meath Hospital, a most
Mk. Macnamara on Epittaau: 33
remarkable case of epistaxis, resulting from mental emotion; far the
particulars of which, as also for the greal ability and zeal he dis-
played in the treatment of the case, I am indebted to my friend,
Mr. Mulock, who at that time filled the responsible posl of resident
Burgical pupil.
E. 1*., aged 26 years, admitted into Meath Hospital, 9th October,
1861 ; Buffering from severe epistaxis. She had, earlier in the day,
applied for relief, and Mr. Parr had suggested, what la; has on
repeated occasions found of great service in almosl every variety
of hemorrhage — ergol of rye, which, however, iV< »m her condition
was contraindicated, she being four months advanced iii pregnancy;
she accordingly received a mixture of the solution of acetate of mor-
phia, acetate of lead, tincture of digitalis, syrup and water; was
ordered, on her return home, to remain quiet, and to keep wet
cloths round her head ; this plan of treatment had some temporary
effect, but in a short time the hemorrhage returned with increased
violence ; the patient came back to the hospital, and Mr. Mulock
plugged both anterior and posterior nares; in despite of which,
however, the blood forced its way out several times in a most
uncontrollable manner, and was only, for short periods, arrested by
continued streams of cold water. Mr. Macnamara saw her in the
morning, when the hemorrhage appeared to be checked, but
recurred again several times during the day; the patient became
much blanched, exhausted, greatly terrified, pulse dierotous. In
the evening Mr. Macnamara was sent for, and, by his advice, the
plugs in the nares, both anterior and posterior, were withdrawn ;
the patient was made to insufflate a saturated solution of a powder
composed of equal parts of tannic acid, sulphate of alum, and sul-
phate of zinc ; the plugs, enlarged in size, were then re-introduced,
the anterior ones steeped in a solution of muriated tincture of iron,
and a large blister was applied to the nape of the neck. In despite
of all this, the hemorrhage recurred on several occasions in con-
sequence of the patient persisting in removing the anterior plugs,
but was always much controlled by the use of the saturated solution
described above, combined Avith the internal administration of the
muriated tincture of iron in full doses. She slowly convalesced, with
occasional returns of the hemorrhage, and at last, however, left the
hospital on the 26th October; since which period she has had
no relapse. In this case she attributed the attack of epistaxis to
profound grief for the loss of her father, who had died some short
time previously.
VOL XXXIII.. NO. 65, N. 8. D
Mb m u namara on i
) of the in« .-t remarkable uris thai I ever wit-
nee - in fche j of fche late well-known Mr B li , to
wli [stance, on several occasions, 1 lummoned for most
severe hemorrhage from fche noee; without a momenta notice ■
gush of blood, of the most profuse character, would take place from
the nostrils, and more than once the quantity so Lost would i
a pint in amount; he was of :i spare habit of booty— anything but
of an apoplectic appearance never experienced any premonitory
symptoms, and yet these attacks of epistazis were persistent in
character, and grave as to the amount of blood Lost. If in attend-
ance earlv after their occurrence, I was able to regulate, in a great
measure, the quantity of blood so lost, but were any time allov.
to elapse, the loss of blood was sure to be serious in quantity. The
plan pursued was the diligent use of the saturated solution employed
in P's. case; the application of a well exhausted cupping glass to
the nape of the neek, and, subsequently, of blisters in the same
region, coupled with the free administration of stimulants, wine, &C,
Circumstances induced as to suspect that he had a heart of dege-
nerate muscular structure, a suspicion that was subsequently verified
by the post mortem examination of his body; his death occurred
very suddenly, after about half an hour's Buffering of intense
dyspnoea, and the muscular structure of the heart was found much
softened, friable, with a quantity of fat superimposed on it ; and oil
globules were easily, on pressure, afforded from its walls. In this
case I have no hesitation in ascribing the epistaxis to the condition
of the heart, nor is it the only ease that I could adduce, were sueh,
in my opinion, necessary.
The influence of splenic engorgement in producing epistaxis has
long been admitted by all authors on the subject. I should, there-
fore, not introduce the following ease, but that, independent of this
complication and connexion, it deserves to be recorded.
Early in this year 1 was summoned to visit a young lady, appa-
rently in the enjoyment of robust health; she complained of a
deep-seated pain in the left side, and <A' a sense of swelling and
enlargement in the region of the spleen. She stated that for some
time she had, without any accountable reason, been subjeet to slight
epistaxis; her general health had been good, but the pain in the
side and the sense of swelling there, were most distressing. In every
other respect her general health appeared to be unimpaired. The
gentleman who had been in attendance previous to my arrival, had
leeched and blistered her over the seat of her uneasiness, with,
Mb. Ma< \ \m m:a on Eputan 95
however, bul little benefit. A careful examination Left n<» doubl
on my mind thai thai side wae considerably larger than the other,
and the impression forced itself on my mind thai it vras some lesion
of the spleen; al :ill events the disease, whatever it mighl l>c. was
clearly situated in the abdominal, and no1 the thoracic cavity; .-till
her general appearance contraindicated any strumous or malignant
affection, and her history entirely put aside all possible connexion
of the allcclion with ague; she had DO Bymptoms to warrant such
an assumption— had never lived in any fenny or marshy district ; in
fact, previous to the attack, having been for some time resident in
the healthiest part of one of our most salubrious outlets — Ivath-
mines. The treatment adopted, after some time seemed so much
to improve her. that my visits were considered no longer necessary.
On the very night of the day on which I left her, the old pain and
sense of swelling returned, but in a ten-fold more aggravated form.
Next night she had intense rigors; all next day and night a con-
tinuation of the pain and swelling, but, if possible, in a more intense
form, and the following morning, after a night of sleepless agony,
she felt sudden relief, following a sensation as if something burst
internally whilst throwing herself about from side to side, in search
of some relief from her agony, in change of posture ; she fell asleep,
and, after a few hours, awoke with a feeling of intense nausea, called
for a basin, and threw up from the stomach very nearly a quart of
healthy laudable pus, mixed with copious streaks and clots of blood ;
for some days after this, the sensation of nausea at intervals
returned, and she recovered in about ten days, without one other
bad symptom. In this case, the preceding epistaxis was evidently
the result of splenic engorgement — an engorgement which subse-
quently degenerated into suppuration, and terminated, most for-
tunately, by adhesion to, ulceration through, and discharge of the
contents of the abscess, by the stomach — a view of the case in which
T was, at a later period, supported by the late Mr. Rynd, who kindly
saw the case for me during a brief period of absence from town. Since
then up to the present moment, a period of nearly eight months, this
young lady lias enjoyed uninterrupted good health; for about a
month afterwards she occasionally complained, on any sudden or
violent motion, of a sensation as if something was tearing in the old
seat of pain, but even that symptom has now long since disappeared.
For the following most instructive case of epistaxis, dependent
on renal disease, I am indebted to my friend, Dr. Kidd — I transcribe
it in his own words: —
l) i'
Ml; M w N \ M \i
"Mi l> vi; M vi \ v \i vi: v The leading particulars of the one of
epistaxis 1 referred to, are as follows: A lady, a Dative ol I
mania, Imt Latterl) residing in Pembrokeshire, came under m
in July last, aged about 38, married 1') years, during which she
had l'» miscarriages, but never passed the third <»r fourth month
of pregnancy; she had been under treatment for uterine disea
before I saw her. Wnen I saw her the catamenia had ceased for
some two or three months ; -In- had been suffering much from constant
vomiting and dyspeptic symptoms. She had a very anemic appear-
ance; her lips were white and pallid. For six wick- die had had
repeated attacks of epistaxis, for which Bhe had been treated with
gallic acid. On the least scratch <>r breach of the surface of* the
skin, die bled very freely; even rubbing with her nails caused the
blood to How SO as to stain her dress to a great extent. In such a
state of defibrination was the blood, that the slightest pressure
caused an ecchymosis, and she was covered with black, yellow, or
orange patches; the limbs were swollen and anasarcous. My first
impression was, that the case was purpura hemorrhagica, Imt there
were no purpuric spots. 1 then looked to the gums, but there was
no appearance of Bcurvy ; L next directed my attention to the
kidneys, and here, 1 believe, discovered the cause of all her suffering.
The secretion of urine was scanty, not more than oz. xii in 24 hours,
sp. g. 1010; when boiled, one-eighth of the tube was tilled with
coagulated albumen. After this the anasarca increased and effusion
took place into the cavity of the abdomen. The hemorrhagic ten-
dency continued, and she had repeated attacks of epistaxis; the
worst of these occurred on the ISth of Nov., induced, probably, by
picking at her nose. This continued, more or less continuously, for
2 1 hours, resisting all the ordinary means of stopping it; when her
anterior nares were plugged the blood ran down her throat ; I
thought I should be obliged to plug the posterior nares, but, before
doing so, tried the following method, which proved very effectual: —
1 rolled cotton wool round a probe, and then saturated it Avith
tincture of the muriate of iron, and with this mopped out the nose
a- far as I could reach, having failed with a speculum to find the
bleeding point; I then plugged the anterior nares with cotton, wet
with tincture of the muriate of iron, and made her sit on a low seat
with a chair in front of her, with a cushion on the back of it, on
which she rested her head; in this position the blood gravitated
towards the anterior nares, and was there coagulated by the iron,
and very soon stopped the bleeding.
Mb. Macnamai: \ on Epistaaii. 37
"There was do pain or irritation produced by the iron, and no
return of the bleeding since.
" Fours truly, Q. II. Kim>."
But of all the varied causes of epistazis that I have enumerated,
the most insidious— thai which but too frequently La most over-
looked, and yel which is St potent in its influence — is scurvy.
Each of my readers must have witnessed more than one case in
his own practice illustrative of the truth of this assertion The
following instance — occurring in the practice of one of the iim'-i
gifted physicians, the most accurate observers, that has lived in the
present century, J. P: Franks — is too valuable to be omitted on the
present occasion; and, in my mind, its principal value lies in the
fact of the cause of the epistaxis not having been recognised by so
acute an observer for some time; it occurs in page 136 of the second
part of the fifth volume of his great work — " De Curandis Hominum
Morbus."
" Of internal causes, there is scarcely any of greater potency in
promoting a flow of blood from the nostrils than scurvy ; occasion-
ally, indeed, the scorbutic tendency is not evinced for some time by
any other symptom than this very hemorrhage. For example, Ave
had the charge, at our clinique, of a man from whose nostrils blood
copiously gushing forth induced us anxiously to seek for the cause
of this lesion. The gums of this man (a tolerably strong one), were
neither spongy or bleeding, nor were there any macular on the skin,
or any dyspnoea present. The spleen presented an enlarged and
knotted appearance, as is usual in these countries ; the arteries, fuller
and frequent, struck the finger with a singular harshness; the
patient was hot, and presented the fallacious appearance of inflam-
matory fever. Seduced by these appearances, we opened a vein,
and drew a pint of blood, which, after a time, was densely buffed.
At night a profuse discharge of blood again burst forth from the
nostrils, yet in the morning we found the pulse harder and fuller
than yesterday, and increased symptoms of fever. The venesection
was repeated, and the blood was almost more deeply buffed than before ;
about 10 hours afterwards the blood gushed forth with such violence
that it could scarcely be restrained by surgical means, six pints
having been lost in a very short space of time. On the following
day we found the fulness and hardness of the pulse, or the fever, by
no means diminished by this, but the entire surface of the body in
every direction covered with scorbutic maculae. The debilitating
plan of treatment on this account being abandoned, we instantly
\1 R M \« s \ m \i;a on I U.
had reooui uiiic, with lemon juice and sugar, and
under the use of tonics and of a nourishing diet, in a short space of
time had our patient convalescent. A few months afterwards we
had another example, Bimilar t»> this, in a young man with an
iciated and pallid frame from whose nostrils blood would fre-
quently gush forth, but principally when attending our clinique. 1I»-
also, as in the last case, presented to our notice a full, frequent, and
vibrating pulse; venesection produced for us blood thai quickly
became buffed, but it was not aide to prevent the return of the
hemorrhage. After a time, on account of the increase of the fever,
and of the hardness and frequency of the pulse, we had recourse to
another bleeding, which was attended with a similar appearand- of
the blood; but it was in vain that thus we tried to cure the disease.
Hence, although the maculae were not present, still aware of this
[!>utie diathesis, and remembering the former case, we order
bark, with better diet, and an allowance of good wine, and cured
our patient under the rapid influence of this more judicious plan of
treatment."
In extracting these oases from the works of J. V. Frank-. 1
consider that but little apology is due to my readers; at the present
day the value of the writings of this truly remarkable man is but
very insufficiently recognised — a fact principally, in my opinion, due
to the non-existence (so far as 1 am aware), of any edition ot his
works in English. The new Sydenham Society would undertake
a task most acceptable to our profession were they to produce for
us a good English version of the masterly treatise from which I
have translated the foregoing case-.
The influence of disturbed cerebral circulation is but too
generally recognised to require here the record of any cases to
establish its existence. The following case, however, (of which 1
only give a sketch), is. in many particulars, so interesting, not alone
on account of this connexion, but also as showing the relief that may
followr the depletion so produced, that I am induced to repeat it here.
Early in last year 1 was asked to see a young lady, aged about
IT) years, under the following circumstances: — She had been for
some time under the care of my distinguished friend, Dr. Wilde,
for conjunctivitis of an exaggerated character; gradually, however,
the following additional symptoms presented themselves — intense
pain in the head, much aggravated by the recumbent position —
constant moaning, persistent even during sleep ; in this stage of her
illness an hype aesthetic state of the skin, so much so. that no
Mi:. M a< a \m \i:a on Epistaais, 39
matter how gently she was touched, it would arouse her from
apparently the profoundest Blumber; but the most remarkable
feature in the case, and thai for which I was consulted, was the
suddenness with which she would tall into a state of profound sleep.
Sitting in her chair, in the midsi of a conversation apparently of
the bighesl interest far her, in the middle of a sentence, her chin
would drop forward <>n the sternum, and she was in a profound
slumber — so profound that the loudest noise could not disturb her.
but, the slightest /<>kc/i, and she would start up as wide awake as it'
she never had been asleep; the same phenomenon would OCCUT at
her meals, in the midst of the process of mastication, with the
morsel still in her mouth, suddenly would she drop off asleep, and
many was the time that her relatives dreaded lest she would thus
he choked; coming down stairs she would lean up against the wall
and be off to sleep. The catamenial period had presented itself a few
months previously, and, in this respect, everything was normal-
But perhaps the most painful scene was to witness her at the piano
(she was highly educated, and for her years an accomplished musi-
cian) ; on more than one occasion her aunt would ask her to play
for me some piece or other of music. The first few pages would be
played with great spirit and accuracy, but wdien she came to the
last page or so, one could easily recognise the struggle with which
the performance was carried on, and the last few bars were painful
beyond description, for the slow laboured effort with which she
concluded the piece — then a deep sigh, and then she was once again
fast asleep. This state of affairs continued for some time, becoming
each day, if possible, worse, and the pain in the head became so
intolerable when she assumed the recumbent position, that at last
she resolutely declined going to bed at all, and for many weeks
passed her nights in the erect position in an arm chair ; thus she
expressed herself as being free from pain. An ingenious experiment
was devised by her father to see whether this pain might not be
hysterical; she was allowed to go asleep in the erect position, and
then gently dropped into the recumbent one ; after a moment or two
deep moans evinced that even in her sleep this position gave rise to
the intolerable pain in the head, and after a few further moments
of intense suffering, she would completely awake, and at once as-
sume the erect position, with very great comparative relief. For
the purposes of this paper it would be idle to mention the many
phases, complications, and various plans of treatment adopted in
this case; suffice it to say. that her convalescence may be dated
Ml; \| U \ \ M \l: \ /
tVuin a rather -harp attack of epiri aid this oocaring
eated applications of leeches in differenl directions about the
I, b) which means depletion had been carried on at farai pre
judged that it could Ik' done with prudence.
For many pears it has been discussed (with more real than cor-
responding amount of benefit in the treatment of the di
whether the blood in epistaxis he furnished by the reins, arteri
or capillaries. Franks, in the treatise to which 1 have already
alluded, states, that it is difficult to decide whether it he from the
reins or arteries that this blood he poured forth; but that he has
himself frequently witnessed, in this situation, a varicose condition
of the reins. " Num vena*, nuni rero arteriaa hune fondant, 1
arduum est dicere. \n chronico profluvio raricosum saspe indolem
renarum Bubesse Dovimus; in eo, quod hypersthenicum est, arterial
nunc besas, nunc finibus quibus rorem bo naree exhalant, dilatatai
BUSpicamur." Now, when BO competent an authority state- that he
has himself witnessed anything, we are hound to accept it as a fad ;
hut to the " BUSpicamur " we may be permitted to place on record
our expression of dissent — the ressels that supply the nose are
entirely of too small a calibre to account for the profuse hemorrhage
that we occasionally, nay frequently, witness in this situation; and
for manv years past, I have been at a Loss, satisfactorily to account
for the phenomenon, until, in a conversation that I had on the BUD-
j( t with my valued friend Dr. Ledwich, he mentioned to me what
mis to be the true anatomical reason, tor which, he himself was
indebted to some German authority, whose name, however, he now
forgets. This gentleman drew attention to the existence in the
turbinated bones of channels or depressions, with which, of course,
every practical anatomist had long been familiar. Across these is
stretched the mucous membrane lining the nostril, converting th<
channels into complete canals or sinuses. In these the yenous blood
exists always in a state of static, for the purpose of allowing the
transudation of that fluid which should always lubricate the Selmei-
derian membrane. When, from any cause, a number of these are
ruptured, of course, we have a profuse hemorrhagic discharge; and
their very anatomical configuration is sufficient to explain why, in
many cases it is so difficult to check the bleeding; whilst if the
hemorrhage depends on an anemic or gpanemic state of the consti-
tution, this condition of affairs is most favourable to the continued
and persistent drain of blood from the system. Believing, as I do,
that this is the true explanation of the source from whence the
Mb. M\(\\m\i:\ on Epistaxk, 41
blood is furnished, I must beg of my renders to carry it with them
in their minds, as, in explaining the efficacy <>1 some of the plans
suggested for treating epistaxis, we shall have occasion to revert to
this anatomical arrangement.
As to the premonitory BymptomS that usher in an attack of epis-
taxis. they may l»e divided into remote and immediate. The
remote ones having for their seat the position, in the body, of the
visCUS in which the cause originates — the immediate ones in the
majority of cases being trifling, and so insufficiently marked, as not
to arrest the attention of the patient until the hemorrhage sel in.
The former of these would open up so wide a field, that I musi
content myself with simply reminding my readers of the variety of
causes on which the epistaxis may depend; and in cases where the
epistaxis is of repeated occurrence, attention to the symptoms
generally associated with each of such diseases will be sufficient to
warn us of the impending danger. The immediate symptoms are,
as I have already stated, of so vague a character as but too fre-
quently to escape altogether the patient's attention ; perhaps of all,
the most frequently present is a sensation of titilation and itching
of the nares ; in many we meet with a feeling of fulness of the head,
frontal weight — varying from a feeling of uneasiness to positive
vertigo, tinnitus aurium — sense of fulness and constriction in the
large veins of the neck, spots before the eyes, flashes of light ; in
some extreme cases, a sense of fulness and positive pain in the
neighbourhood of the vertebral vessels; the patient sometimes is
heavy and somnolent, at others fidgety and restless ; but in the
great majority of cases, the first intimation the patient has, is the
escape of blood from the nostril, varying in quantity from the flow
guttatim, to that pleno rivo; this, in the majority of cases, comes
but from one nostril, occasionally, but far more rarely, from both ;
but, even in this case, we will remark that the flow is far more
profuse from one than the other nostril. It has long been a
favourite theory, that the blood escapes from that nostril which
corresponds to the side in which is seated the cause of the hemor-
rhage— for instance, if it be from congestion of the right lung, the
blood flows from the right nostril, and vice versa; if it be in the
liver that the disease lies, the blood will escape from the right
nostril, but from the left, if it be in the spleen, and so on; now,
though my experience will not lead me to vouch for this statement
as being a law of universal application, still, I am inclined, to some
extent, to vouch for its truth. As far as my memory serves me
. in most of tin- i i ts phoid fever in irhich I hare iritneased
tliis phenomenon, the blood ha ped from the left nostril; and
here ire have sound reasons for believing the spleen to be the riscus,
on the engorgement of irhich the epistaxis depends ; whilst in o
e ;u Least of hepatic disease, in irhich 1 iritnessed repeated
hemorrhage from the note, it invariably oame from the right
nostril. Whether this, however, be ■ coincidence or * law, can only
be decided by repeated, accurate, and extensive observation; it may
be remarked, however, that Franks inclines to the adoption of this
theory.
Perhaps one of the most important questions a medical man can
be requested to decide, is that involved in ■ correct prognosis of
the ease which lie i> called upon to treat; second, and second Only,
to bis accurate diagnosis and judicious treatment of the case in
question. Fortunately for ns, and occasionally more fortunately
still for the patients and their friends themselves (for " where Igno-
rance is bliss, 'tis folly to be wise"), we are not bo frequently in this,
as in other Lesions, pressed for our prognosis. As I have already
stated, people are in the habit of looking on epistaxis as so common,
ordinary, every-day an occurrence, that they rarely look beyond
the present, and so as the hemorrhage be checked, give themselves
no further trouble about the serious questions that may be involved
in the correct interpretation of the state of constitution giving rise
to this, but too frequently, most erious and significant affection.
If the Burgeon, however, has but traced the symptom to its origin,
he will experience but slight difficulty in coming to as accurate ■
conclusion on the point as our finite judgment will admit of. In
general terms, 1 may express it as my opinion, that the gravity of
the case, ceteris paribus, increases with the years of the patient.
In childhood and in early youth we frequently meet with cases of
epistaxis of but slight importance, transitory in their nature, and,
most probably, caused by abdominal congestion, dependent on some
error of diet or other passing cause; not so, however, in the more
advanced periods of our life; every such case demands at our hands
most careful investigation, and just consideration of each and every
cause that mav oiVe rise to it. Should we be so fortunate as to
arrive at a correct solution of this problem, we may find ourselves
in a position to be, if not of substantial service to the patient
entrusted to our care, at all events, of being able to give an accurate
prognosis of the course that the case is likely to pursue. When
the epistaxis occurs in any of our continued fevers, it may, as in
Mb. Mai namaka on Ujnstcu-is. 43
typhoid fever, lie Looked on only as a norma] occurrence or symptom
tO be expected in the natural eom>e of events ; OT it may he of mo-t,
serious, if not fatal, import, as in the ad\;meed periods of typhus,
scarlatina, measles, small-pox -in these CaSCS evidencing a deterio-
rated condition of the blood itself, the more serious the later it
oocura in the progress of the disease. In acute scorbutus, and in that
condition of the blood met with in patients who ha\e heen subjected
to protracted immersion in water, epistaxis, though rarely a soli-
tary hemorrhagic symptom, is a most serious one — most intractable
in its character, and of the gravesi importance. When it owe- it-
origin to disturbed cerebral circulation — when it is, in fact, accom-
panied with other evidences of determination of blood to the head —
the prognosis must be grave, especially if the patient will not submit
to the plan of treatment sure to be suggested by the judicious
physician; here not only is it a warning kindly given us by nature
itself of the impending danger, but it acts as one of the safety
valves by which the danger may be warded off. When accom-
panied with other symptoms of the existence of the so-called fatty
heart, our prognosis must be grave, and so on, the prognosis in
each case depending on, and to be measured by, the importance of
the primary lesion to which the epistaxis owes its origin.
When the surgeon is summoned to such a case, the prominent
idea in the mind of each non-medical bystander is — " how he will
stop the hemorrhage;" the first question, however, that the real
master of his art should decide is — whether he should take steps to
stop it all or not ; a question only to be correctly answered by taking
into account the true cause on which the epistaxis may be dependent.
In general terms it may be laid down that, if the epistaxis be of a
sthenic type, it should not be arrested, but, on the contrary, be
encouraged, always so long as it be kept within due bounds. So
long as the pulse preserves its force and rythm, the eye its lustre,
the cheek its colour, the extremities their temperature, the heart its
normal impetus and force, no serious danger can, but, on the con-
trary, good will, accrue from the loss of blood; should it, however,
exceed these limits — should symptoms of faintness and flagging
circulation evince themselves, then, but not till then, is the surgeon
called on to interfere. In epistaxis of the asthenic type, however,
we cannot lay clown so general a mle ; occasionally it may, even in
these cases, be of benefit, but far more frequently is it likely to
prove prejudicial; certain it is, that in this condition of affairs in no
ease would it be justifiable to allow the hemorrhage to proceed to
I I Ml; M vi \ \ \i vi: \ on I
anything like ;it an extenl m in the preceding Indeed, in
tin s, perhaps the Bafest rule when ire take into consideration
tin- time that ma) have been spent in procuring the attendance of
the surgeon, the quantity of blood that, in all probability, will ha
been lost ere bis arrival — will In- to exert oureelvefl to arrest the flow
ai speedil) as possible. Nor can this, in the majority of cases, be
ily effected; indeed, in the more Berious cases, it is but too
frequently entirely impracticable; and, even if successful in our
exertions in this direction, it is only but to Bee them baffled by an
ipe of blood through some other channel. In such cases our
ry exertion should be directed to the employment of such means
at will effect a radical change in the character of the blood itselft
superadded to those that we may either locally or generally use
the purpose of restraining its flow. What those should be, the special
nature of each case will indicate, and without their exhibition other
treatment of the case will be futile.
When we reflect on the means employed by nature, unassisted by
art, for arresting hemorrhage, and which may be concisely Bummed
uj) in four words — contraction, retraction, coagulation, syncope: con-
traction of the open mouth of the bleeding vessel, retraction of the
vessel itself within its sheath, the plugging up of the open mouth of
the vessel with coagulated blood, or the much diminished impetus of
the circulation due to the enfeebled action of the heart caused by
Syncope — when we reflect, I say, on these means, and if we accept
the theory that 1 have already placed before my readers of the source
from whence the blood flows, it will be evident that the first two —
contraction and retraction — are, for anatomical reasons, unlikely to
be of much use in checking the flow of the blood; and that, when
nature plays the part of surgeon, it is by one or other, or both
combined, of the two latter plans she effects the cure. And, in fact,
every day experience establishes for us the truth of that which
theory would suggest — the spontaneous arrest of the hemorrhage,
whenever of a serious nature, being almost invariably attributable to
the mechanical pressure of a coagulum — a fact which tends much to
confirm me in the opinion that what has been already put forward
is the true solution of the questio iwcata, the source from whence
the blood springs in epistaxis. And it is most important that these
clots should not be disturbed; in this case the nitnia diligentia of
the surgeon is sure to do mischief and cause a return of the hemor-
rhage, if it lead him, before some days, to disturb the plug placed by
nature in the very position best suited for controlling the bleeding,
Mr. M \< \ \m lb \ on Epistaxis. 45
Mini made by ber of the materia] Lead likely to injuriously affect the
patient.
Once decided on interfering with the hemorrhage, it behoves the
Burgeon to consider the means which hi- arl has placed :it his dis-
posal lor that purpose; these we will find may be classified under
two heads—genera] and local terms which explain themselves, and
which we .-hall proceed to disCUSS in the order in which they arc
written. To the class of genera] remedies belong all those medicines
recognised as astringents; each one of them in its turn lias had its
advocate; and after all, perhaps, hut little difference, if. they he pos-
sessed of an equal amount of astringency, exists in their respective
merits: thus we may administer internally galls, tannic and gallic
acids, catechu, kino, oak hark, logwood, matico, the mineral acids,
alum, the more astringent of the preparations of iron; or Ave may
administer sedatives, such as opium and digitalis, or medicines that
comhine both a sedative and astringent property, such as the acetate
of lead ; or we may depend on purgatives, or the astringent vegetable
tonics ; or that class which act on the blood, checking the scorbutic
tendency, such as fresh vegetables, the vegetable acids, and pre-
eminently of these lemon juice; or we may prescribe a medicine
first suggested by Spajrani, and favourably reported on by Negrier,
Pignacea, and others — the ergot of rye ; or we may order turpentine,
or the chlorate of potash, or camphor combined with opium, and
many others, the use of which has been signalized from time to time,
but the value of which has not had the stamp of experience.
Now, to the most superficial mind, it must be evident that Ave
cannot prescribe these remedies indiscriminately in every case of
epistaxis. Why one should be preferred to another must depend
on the cause of the hemorrhage; if it be sthenic in its type Ave
administer such medicines as will produce a decided impression on
the system, ivhilst at the same time we encourage the flow of blood ;
perhaps in such a case as this no combination will be found more
useful than salines Avith digitalis, as in this formula: —
IJ Infusion of roses, to eight ounces; sulphate of magnesia, two
ounces; tincture of digitalis, two drachms; dilute sulphuric acid,
two drachms ; of Avhich two table spoonfuls should be taken every
second hour till the effect be produced.
liepeatcdly haAre I seen marked benefit from such a combination ;
nor, on the cessation of the epistaxis, is the treatment to end here.
The treatment still must be continued, directed in such a manner as
to correct the constitutional state that gives rise to the hemorrhage,
Mi; M L< s \M UiA
and the diet and habits of life of our patient must rum.- in for their
full share of attention at tin- handi of the practition
In moh it ii that the abstraction of blood, i ither
l)v leeches, cupping, or venesection, has been advocated. 1 can
fully recognise fche value of this practice if it be directed a the
state of constitution giving rise to the epistaxis, and if the flon
blood Itself be not sufficient to produce the desired impression on
the system; but, if it be sufficient, this line of practice it most
injudicious. We can procure the required amount of blood by
encouraging the epistaxis; why then have recourse to other
for its abstraction? Ami if the hemorrhage has already exceeded
duo hound-, why increase the mischief by taking more blood away?
If the epistaxis be salutary, but not sufficient in quantity, then ire
may deplete, but we deplete not to arrest the hemorrhage, but
because it is not already sufficient, and, in that case, our depletion
is directed, not against the epistaxis, but against the disease that
gave rise to the epistaxis. When conducted on such principles the
abstraction of blood is based on sound theory; but to talk of
venesection, leeching, or cupping, as amongst the remedies for
epistaxis, as such, is, in my opinion, most erroneous. The cupping
to which I now allude is, however, not to be confounded with dry
cupping — a most useful remedy, but applicable to quite a different
condition of affairs to that which we are now considering.
Presuming, however, that the case be one calling for prompt
suppression of the hemorrhage, on which of these constitutional
remedies are we to rely? The answer to this question is — that
this will entirely depend on the state of constitution present in the
subject of the epistaxis. If it be a simple case of passive epistaxis,
occurring in a delicate patient, and owning, for its proximate cause,
some trifling congestion, due perhaps to position, such as reading
for a long time with the head bent forward, &C., &c., we cannot
do better than at once have recourse to five or six grain doses of
firesh prepared powder of ergot of rye, repeated according to the
emergency of the case, every 10 or 15 minutes. The first person
who drew the notice of his professional brethren to this interesting
property of the seeale cornutum, was Dr. Spajrani, in a communi-
cation published by him in Omodeis Aniudl UniversaU di Medl-
clna e Chirurgia. In addition to cases of hemorrhage from other
situations in which he found it of service, he recorded two cases of
epistaxis in which its exhibition was attended with the happiest
results, and since that period (1830), it has been tried by many
Mi:. Mac \\m.\ka on Epiataait. 47
other practitioners, with varying success; its most zealous advocate,
however, is my old valued friend, Mr. J. J. Parr, in whose name
the old students of the institution will recognise the efficient and
experienced resident medical officer of the Breath Hospital; he
informs me thai a Long and frequently repeated experience of it
justifies him in considering it a remedy of sovereign utility, not only
in this, but in many other forms of hemorrhage. In this class of cm
I have found a mixture containing the acetate of lead in combination
with the acetate of morphia and distilled vinegar also of great sen ice ;
and. after we have checked the flow of blood, wc will find the pre-
parations of cinchona in combination with the dilute phosphoric aeid,
or of quinine in the form of pill, combined with camphor and the
extract of henbane or of hops, of great value in correcting the
I peculiar cachectic state that predisposes to a return of the hemorrhage.
In that form of passive epis taxis connected with the anemic con-
dition, I have found few remedies of greater service than the tincture
of the sesquichloride of iron, in tolerably full doses. I generally
prescribe it in combination with some of the pure vegetable bitters,
such as quassia or columba, in from 15 to 20 drop doses every three
hours ; and indeed, in my opinion, the treatment of the majority of
cases of asthenic epistaxis will not be properly concluded without
the subsequent exhibition, for some time, of somewhat smaller doses
of this most valuable medicine. It corrects the cachectic condition
which predisposes to the return of the epistaxis ; wrhen present it
controls it most sensibly, and in every particidar materially improves
the general health of our patient.
In that form of epistaxis which, contemporaneously with hemor-
rhages in other situations, appears in purpura, in those whose blood
has undergone some serious depravation in the advanced stages of
wdiat are known as blood diseases, or by long exposure to wet, I believe
that I am but expressing the unanimous opinion of the profession
in giving the palm to turpentine, either alone in capsules, or in the
form of emulsion, or combined with brandy or whiskey, in the form of
punch. If in these cases medicine is to be of any use we must place
our reliance on turpentine. The punch to which I allude is made
by adding from half to a full wine glass full of spirits of turpentine
to a tumbler of brandy or whiskey punch, and administering it, in
severe eases, to the patient in as short a space of time as he can
swallow it. The extraordinary results that ensue in apparently
hopeless cases from the exhibition of this horrid dose require to be
witnessed before they can be believed.
L£ \! i; M \t NAMAKA
Th. aal and local means relied on fo ting i pi
is varied as thej are numerous proceeding from the simplest of
popular remedies, such a- dashing cold water on the nares, back of
tin- neck, pubes, ^Ve., up to one, occasionally, of tlu- most trouble-
some operations in surgery— plugging the posterior nares. We
shall consider them in the order in which they have been mentioned.
The dashing of cold water on the hack of the neck, on the to]
the head, on the os front is the nares, and the pubes, is, in many
oases, of signal service; yel it does not always act exactly in the same
way. When applied in the immediate vicinity of the hemorrhs
it acts by repelling the blood from the part, and bo allowing time
for the formation of a clot orcoagulum, by which the bleeding point
is plugged up. When applied at a distance from the part, such as
over the pubes, the first action is to repel the blood from, the
»nd to determine it to the part, the result of which is remotely
to affect the circulation at the bleeding point, and by the temporary
respite so afforded to allow of the formation of the coagulum. It is in
this way also that the popular remedies — the key of the hall-door,
or the cold smoothing iron, applied to the hack of the neck — act,
first by repulsion from, and then by derivation of blood to a part
remote from the position of the lesion. I shall presently have
occasion to point out that, in some of our more strictly surgical efforts,
we have copied those homely popular remedies, and that with signal
advantage to our patients. A remedy which latterly has become BO
popular that it may be ranked amongst those of popular origin, owes
fust suggestion to M. Negrier. I allude to the elevation of the
arm, of the side affected with the epistaxis, over the head, and its
retention in that position lor some time. M. Negrier speaks in high
terms of the success attending this practice; and explains it on the
theory that the heart has but a given amount of propulsive power,
which is exhausted in propelling the blood up along the arm against
gravity, and thus the bleeding vessel is deprived of it to a certain
extent, and the hemorrhage thereby checked. Mr. Journey., a
Belgian army surgeon, records some eight and twenty cases,
occurring in troops marching under a hot sun, in his charge, when
this plan of treatment alone was found effectual. M. Jamain, in a
paper which he published on the subject in the Gazette des Ha-
pitaux, whilst he accepts the fact, refuses to accept the explanation,
which he attributes rather to the erect position so enforced of the
head, in exact contradistinction to that usually adopted by patients
suffering under an attack of epistaxis, who, leaning over a basin, so
Mi;. Macnamaka on Epistcuris 49
congeal the veins of the neck, retard the return of the blood through
them, and thereby favour, l>v the continuance of the hemorrhage,
the expulsion of the clot, in this instanee, ;ilx>rtively funned Cor tin;
sealing up of the bleeding point. And if my readers will now refer
hack to the pathological views that, in a former pari of this paper,
have already heen put forward, t lev u ill mo t hat there are mueh
grounds for M. Jamain's explanation of the successful results of this
plan of treatment. In the erect position of the head the ethmoidal
sinuses being brought into the horizontal position, that most favour-
able for the spontaneous formation of a coagulum; whilst with the
head bent forwards they arc in the vertical position, that most
favourable for the persistence of the cpistaxis, and this, independent
of the congested state of the jugrular veins, so induced a state of
congestion that, no doubt, also tends to keep up the continued flow
of blood from the nostril. That the erect position of the head has
much to do with the arrest of the epistaxis, experience has long
since taught me ; I having seen many sharp attacks of congestive
epistaxis arrested by the patient leaving the heated atmosphere
where it occurred, going out to stand at the hall-door, or some
other cool place, with his head held erect, and a handkerchief kept
to the nose to prevent the blood soiling the dress ; in those instances
the position of the head being alone attended to without having
recourse to the elevation above it of the arm.
Founded on the same principles of derivation as the dashing of
cold water, is the application, in various situations, of the dry cup-
ping glass, of blisters, and of the actual cautery. These, wherever
applied, have many advantages ; but, in my experience, are attended
with the happiest effects when applied to the back of the neck, over
the ligamentum nucha?. Of the two former of these I have had
repeated experience ; of the latter I have none, so I shall no further
allude to it than to state its employment was recommended by
Zacutus Lusitanus, who directs it to be applied to the extremities;
and that since his time the actual cautery has been applied to the
nape of the neck, in some obstinate cases of epistaxis, as stated, with
marked benefit. Of the two former plans, however, having frequently
had recourse to them with signal advantage, I should wish to speak
at some length. And first, then, of the dry cupping glass : — This, if
properly applied, is a powerful derivative, but, if improperly, its
employment is worse than useless, as occupying, in ineffectual
efforts, time that might lie far better bestowed in the application of
other means for restraining the flow of blood. The way in which
VOL. XXXIII., NO. G5, N. 8. E
Mi: MaCNAMAHA on I is.
the glass should be emplo \a follows: adapt the nee of the
i that of tin- nape of your patient*! neck, the object to
employ as large b glass as tin- situation will admit of, and thui to
increase the derivative action ; but if it be the slightest shade I
large it never can be exhausted effectually, and consequently will
fail in producing the desired effect. Having, then, selected your
glass, plunge it into a basin of boiling hot water, then dry it rapidly
with B towel, smear the upper portion of the inside of the glfl
with spirits of wine — this von do by tightly rubbing it with your
fusee dipped in the spirits of wine — now light your fusee, introduce
it into the glass, and withdraw it rapidly yet quietly, and apply the
glass at once to the desired spot. It* these directions be accurately
followed, the glass will he effectually exhausted, the exhaustion
increasing as the temperature of the previously warmed glass fails;
and an ecehvmosis will be the result, the marks of which will no1
disappear for some three or four days. In applying the glass in
this way, you must take care only to moisten the inside of the glass
with the spirits of wine, not to have any of it present in the fluid
state, as in this latter ease, on introducing the lighted fusee, you
set the spirit on tire, and on inverting the glass over the seat to
which it is to be applied, you bring the blazing spirit in contact with
the skin, and give rise to considerable pain, and, it may be, to a
very severe burn. You should also observe a similar amount of
precaution in dipping the fusee into the spirits of wine, as, if it be
too heavily charged, drops of burning spirit may fall on your patient
and produce similar results; when, however, ordinary precautions
are observed, this is by far the most effectual way of performing,
what is technically called, dry cupping, and the operator must
indeed be a clumsy one, if, after one or two trials, he prove not as
expert as the most experienced professional cupper. This plan of
treating passive epistaxis, as old as the time of Galen, by whom it
was employed, merits more repeated employment than now-a-days it
gains. I am cognizant of its value, and recommend it strongly to
the consideration of my professional brethren.
Analogous to this plan of derivation, but slower in their action,
is the application of counter-irritants in various situations; for in-
stance, the warm foot bath with mustard in it, as recommended by
Chrestien; the application to the extremities of nettles, as advised by
the celebrated Borelli, or of blisters to the nape of the neck, as first
suggested by Niemann. Of this latter I can speak in terms of the
greatest confidence, for some years past having been in the habit of
Mr. M a< \ \m \i:\ on Epiataxis. 51
nsiiig tfaiem with signal advantage; in which line of practice I was
happy to ascertain — in the ooune of a conversation that I had with
him on the Bubjecl some short time back — that I am borne out by so
able a surgeon as Mr. Fleming, one of the surgeons to the Richmond
I [ospital ; he tolls mc that his experience fully corroborates mine,
and that he has never failed in deriving signal advantage in the
treatment of cases of epistaaris from the application of blisters to the
nape of the neck; these, to be of use, must be properly made, about
two inches wide, four to five inches Long, applied along the cervical
vertebra), commencing as close to the occiput as the hair will admit
of, and -hould be kept on at least eight hours.
In some rare cases, where the urgency of the symptoms induced
me to think that a more rapid method of vesication would be
desirable, I have had recourse to what may be termed instantaneous
blistering, by the agency of the strong water of ammonia. The
method of applying this is as follows: — A doubled piece of lint is
to be folded to the desired size ; this is to be placed in a saucer, and
some caustic water of ammonia is to be poured on it ; when saturated
with it, it is to be raised with a dressing forceps, and applied to the
nape of the neck. Some dry folded lint, of a larger size, super-
imposed on it, and the entire covered with oiled silk ; this is to be
left there for a few minutes, and on its removal, care is to be taken
that the skin be not torn away with it ; the result is a blistered surface
of the full size and shape of the piece of lint employed. In this
way we have produced, in a few minutes, the effect that eight hours'
application of the ordinary blister may, after all, fail in producing.
The great objection to it is the amount of pain produced by its
application. In some cases, however, this is a consideration that
may be only of secondary importance.
Of the general remedies these are the most important, and certainly
those upon which most dependence is to be placed, but on them
alone we cannot rely; those remedies which are applied locally
demand some consideration at our hands, and they may be arranged
into those of a styptic or astringent character, and such as act
more or less mechanically in controlling the flow of blood. In the
former class we find every remedy that ever was supposed to be
possessed of astringent properties, from those of humblest preten-
sions to those that undoubtedly are of acknowledged efficacy. It
would but little serve my purpose now to enumerate all that at
various times have gained ephemeral reputation; I shall only
introduce those that I can recommend with confidence to my
e 2
Ml: M LI N v MARA on I
ition, leaving their selection fter to be guided
bi the circumstai H irhich 1 have found to be
of most unvarying valu( powder composed of equal part* of
tannic acid, Bulphate of alum, and Bulphate of zinc. These arc
separately to be reduced to fine powder, and then mixed ae ultimately
( )t* this compound I add about a tea Bpoonful to a
pint of water, and direct the patient to take up in the hollow of hifl
hand what will be contained in it, and to snuff it up into tlie
bleeding nostril, it' the blood be issuing but from one nostril, the
other being compressed, or into both nostrils, if the blood be issuing
from the two. This is to be repeated several times, and during
each interval the head is to be held up crert, a cloth being provided
to catch the blood, and SO prevent it- Boiling the dress. The water
will by no means dissolve the amount of the powder here directed,
hut will suspend it, and, if used immediately after rapid gyration,
it will fulfil every indication. Many other astringent remedies have
been suggested ; for instance, any one of these Bubstancea separately
employed, or acetate of zinc, Bulphate of copper, sulphate of iron,
pernitrate of iron, perchloride of iron, the double salts of sulphate
of iron and alum (as suggested by Sir .lames Murray), the various
vegetable astringents in infusion or decoction, rach as logwood, oak
hark, matico, nut-galls, &c., or combinations of them with the metallic
salts, to suit each Beveral practitioner's taste; but, after sufficient
practical experience of each of these, I have found none to excel
or even to equal the combination 1 have previously described.
Some practitioners laud highly Ruspini's styptic, whilst others
vaunt Pasfliari's hemostatic. Not having ever had occasion to
resort to either, I cannot speak of their value from personal
experience; the latter of these, from its composition, 1 suspect to
be an energetic styptic; it can easily be prepared as follows: — Boil
together eight ounces of tincture of benzoin, one pound of alum,
and ten pounds of water, during six hours, in a glazed vessel,
replacing the water lost by evaporation with additional hot water,
and keep the mixture constantly stirred, then filter; French cotton
steeped in this solution should be introduced as far back into the
nostrils -as possible. Its property of coagulating blood i- very
remarkable, and warrants our employment of it in extreme cases.
In spite of our best directed exertions, we occasionally meet with
eases that will require still further efforts at our hands. I advisedly
say " occasionally," for I am of opinion that these cases are but few
and far between. If the means already suggested be but diligently
Mi;. Mac \\\iai;a on Epistaxis. 58
employed the case musl be an obstinate one thai resists. Eowei
>\w\\ we occasionally meet, ami our consideration musl now be
directed to the other means at our disposal. These arc all, more
or less, modifications of direct pressure, from the spider's web to the
plugging of the posterior nares. Each, one and all, owe their efficacy
to mechanical interference with the escape of the blood. Having
mentioned it, I may here briefly state that spider's wel> moistened
with vinegar was suggested by Chesnau a> a valuable remedy for
epistaxis. Later writers have insisted 00 the existence in the; web
ot" hemostatic powers; hut I believe that any property of this kind
that it possesses is purely mechanical, entangling in its meshes the
blood, and thus facilitating its coagulation, whereby a plug is formed
to seal up the bleeding point; of course, the vinegar, by its
astringency, eo-operates in checking the epistaxis.
Plugs of various kinds have been at different times suggested by
successive writers, Aviccnna, for instance, recommending the
anterior nares to be filled up with plugs of dough, or of a paste
made with chalk. Morgagni suggests plugs of charpie, moistened
with spirits of wine, to be used in a similar manner. Audoin
advises strips of carded lint to be pushed as far back as the posterior
nares, and the bleeding nostril in this manner to be completely
stopped up.
Somewhat analogous to this plan of Audoin is that which Mr.
Smyly, the experienced senior surgeon to the Meath Hospital, is in
the habit of employing. He having been kind enough to describe
it for me, and given me permission to make his communication
public, I shall gladly give it in his own words: —
" My dear Macnamara — I have found the following an effectual
means of arresting the bleeding in cases of epistaxis ; it is easy of
accomplishment, and one to which the patient will readily submit.
" The plugging of the posterior nares presents difficulties which
deter some practitioners from attempting the operation. It is
attended with great annoyance to the patient, not only at the time
of its performance, but during the few days the plug has to remain ;
its removal also is sometimes found to be a troublesome task. No
doubt patients will submit even to this to be relieved from impending
danger.
" I shall not easily forget a case I was called to see seven miles
from town. I arrived in the middle of the night, and found an
elderly gentleman lying like a statue, being not allowed to move
hand or foot, the windows were wide open, the patient was shivering
Mi: M v< n \m IB v /
with odd, his head, neck, And shoulders drenched, and covered with
wet cloths; he was pallid, yet the blood continued to trickle I
the nares being plugged the scene was changed from wretchediu
to comfort. To bis surprixe and delight the patienl mu changed
i comfortable bed, and was told he might, with perfect confident
compose himself to Bleep. I mention this to Bhow the great value
of plugging the nostrils, and it- superiority to other treatment.
" The plan I advocate now is to till the cavity of tin- nose with
slips of lint introduced from before. I prepare ■ few slipe of lint,
about one foot long and halt* an inch wide, doubling two inches of
the first Blip over the end of a Btrong director, I pass it along the
floor of the nasal cavity as far as the posterior nares ; the rest ofthe
Blip is then packed in, and the extremity, which should be made to
taper, is left projecting out ofthe nostril for the purpose of its more
easy removal. After this another and another slip i- thus intro-
duced, until the cavity is full. The first gentleman I practised
this plan upon was a very witty person, who was much amused at
the process of taking out the slips, which he compared to the
unpacking of a portmanteau; he named each slip as it came out
after an article of dress
" I was called by a medical man to plug the posterior nares for a
patient of his. When I arrived the bleeding had ceased. The
gentleman would not see me. 1 explained the above-mentioned
method of proceeding to the medical attendant, who had, in the
night, occasion to put it into practice; he found it easy of accom-
plishment, and perfectly successful in its result.
•• Believe me to be yours truly,
" J08IAB S.UYLY."
Desault and Larrey were in the habit of employing a piece of
linen sewed into the shape of a glove, which they pushed through
the anterior nares backwards towards the pharynx; this was then
packed with lint or some such material, and then drawn forwards,
so as to press on the surrounding parts, and thus by direct pressure
seal up the bleeding point. Though Larrey speaks highly of this
procedure, still it presents many and obvious difficulties; — first,
accurately to pack, and secondly, when it has discharged its duty,
to unpack it. Mr. Bell improved on this plan by substituting for
the linen bag, a piece of the small intestine of a pig ; this fastened
at one end is introduced as far back as the pharynx, and then filled
with fluid or air, and pulled forcibly forwards, so as to act as a
Mu. M\( \\m\i:\ on Epiitaah. 55
plug. In the Mill volume of the new series of the Medical Tii/irs
and Gazette^ p. 493, we find extracted from the Boston Journal an
improvement on this suggestion <>f Bell's by Mr. Coate. I repro-
duce the passage: — "Plugging in Epistaxis. — Dr. Coate employs
a very simple contrivance; it consists in a piece of pig's gut, eight
inches long, tied at one end. and then turned wrong side out. BO
that the knot may be on the inside, on a child's silver canula. By
this canula it is introduced through the QOSC to the pharynx, and
then blown up, and tied an inch or so outside the nose. He often
introduces a spoonful of saturated solution of alum into it. It plugs
Up both the posterior and anterior Dares thoroughly, and to remove
it. it must he pricked, and gently twisted or drawn out. Dr. Coate
always keeps a yard or two of gut on hand in a bottle of diluted
alcohol.11 Franca also recommends a plan of treatment based on
similar principles, and these have been improved upon by M. Martin
St. Ange, in his Rhinobyon. This has, superadded to a small bladder,
a silver canula fitted with a stop cock; the bladder is to be pressed
back into the pharynx through the nostril. Through the canula
either air or fluid may be passed to dilate the bladder, when the
stop cock is turned, and the dilated bladder is then to be drawn
forward until it is firmly pressed up into the posterior nares ; the
anterior are then plugged, and the operation is concluded. To
withdraw it, the cock is turned, the fluid or air allowed to escape,
and the instrument can be withdrawn, carrying before it all coagula,
&c. Those who have employed this plan, speak highly in its
favour. Its great merit consists in no interference through the
mouth writh the pharynx being required, as in the ordinary manner
of plugging the posterior nares, which we shall presently describe,
a point of no mean importance, as all know who have ever performed
this operation, and in the great facility with which it can be effected
in the younger periods of life, when our patients are not usually so
manageable as in more advanced age.
The method generally pursued in these countries of plugging the
posterior nares, is so well understood, that it requires but a very
few words of explanation at my hands. ; it can be done either with
the ordinary No. 10 gum elastic catheter, or with that most inge-
nious instrument devised for the purpose, by M. Bclloc. I shall
first describe the steps of the operation as performed with the
assistance of the gum elastic catheter, a correct comprehension of
which will facilitate my description of Bcllocs instrument. Having
prepared a ping composed either of folded lint or of a piece of
Mi: \1 \< N v M ai: \ on I
kbout tin- Bize and shape of the thumb, il if to be tied
firmly in the oentre bj a piece of sound twine, about 18 inches
long, the knot being tied in the middl< to 1* :t \ « - two equal
Lengths of tin* twine hanging ai either side; you then pass through
the eye of the gum elastic catheter, from 1 5 to L8 inches of stout
ligature silk, and pass the catheter almost directly backwards, aloi
the Hour of the nares, until it reaches the pharj nx ; the patient ii then
directed to open wide die month, and with a long dressing foro
0*4 end of the -ilk is caught, and drawn forward out of the mouth,
w bilert the other, on the withdrawal of the catheter, hangs out of the
nose; the portion of silk that is outside the mouth is now firmly
attached to one end of the twine that has been tied round the plu
and by pulling on the end of the silk that hangs outside the u<
we draw it also out through the nostril, and are in a position to
proceed to place our plug in situ; grasping the plug between the
index and middle linger of the left hand, we guide it hark into
the pharynx, and then up into the posterior nares, whilst with the
right hand we draw forward the string that appears through the
nostril, and pull the plug firmly into the required position; then
the anterior nostril is to be plugged, and when that is done the
string is to he again pulled firmly to Becure the plug tightly in its
position, then rolled round a small quill of lint, and seemed with
sticking plaster in some convenient position about the face. The
Btring that hangs out through the mouth is to he fastened in a
similar manner; taking care, however, that it is to hang loosely,
in contradistinction to the nasal end, which is to be firmly on the
stretch, so as to secure the retention of the plug in the desired
position in the posterior nares.
Now, in description, all this seems simple in the extreme, but,
in practice, it is anything but simple; a more troublesome pro-
ceeding, as this but too frequently proves, exists not amongst
the minor operations of surgery. The patient, terrified at the
loss of blood, half choked with the rush of blood down the throat
ensuing on the position he is compelled to assume to allow the
surgeon to catch and draw forward the string, and especially so,
if of tender years, becomes unmanageable, and even in the most
docile it is not always an easy task to lay hold of the string,
situated as it is far back in the pharynx. To obviate this in-
convenience, Mr. Belloc has invented an instrument in size and
shape resembling a number 7 silver catheter, but of exactly one-half
the length. At its extremity it is furnished with an eve, which,
Mb. M.\( namai.'a on Epistaais. ' «
however, is nol attached t<> the body of the catheter, but to b Bpring
thai vu\\> down within the catheter. Along this spring is a Btylet,
which can be drawn oul bo b to double the Length of the instrument,
mid which, by a .-crew, can be attached i<> the end of the Bpring.
When so arranged, by pressure on thai portion of the instrument
thai is outside the nostril, the Bpring is protruded in the pharynx,
carrying with it the eye armed \\ i 1 1 » the Ligature; this, in virtue of
the curvature of the Bpring, presents in the anterior portion of the
mouth, and thus enables the operator with ease to catch the Ligature,
and then the subsequent steps of the operation arc exactly those
already described. This instrument, with difficulty described, will
be at once understood by the most cursory inspection, and will be
found a most valuable adjunct in performing this troublesome
operation. Still even it requires some dexterity on the part of the
manipulator. In that which I possess the curve of the instrument
is too great, and if it be carried too far backwards, the eye, on
pressure, will not come forward on the dorsum of the tongue, but
will, on the contrary, go down the throat, and thus complicate
instead of facilitating the operation. We should, in its employment,
not seek to see it at the back of the pharynx, but, when ice judge
that it should be thereabouts, press down the button, and we will have
the gratification of seeing the armed eye travelling along the dorsum
of the tongue, and can then readily seize the string that will facilitate
our every other step.
Having secured the plug in its proper position in the posterior
narcs, in the majority of cases of epistaxis, is not alone sufficient to
arrest the hemorrhage, it still will be essential to plug the anterior
nares, for this reason, that it very rarely happens that we can place
the plug on the exact bleeding point, and if we fail in so doing, all
that we will have succeeded in effecting is the occlusion of the
passage backwards, leaving that forwards open for the escape of the
blood ; if this, though, be also shut up, the effused blood is retained
in the shut sac so formed, coagulates, and becomes itself the plug
by which the further hemorrhage is arrested.
Presuming that the operation has been properly performed, and
so far has proved successful, our next consideration will be, how
long are these plugs to be let to remain? After 24 hours the
anterior ones may be removed, but that in the posterior nares must
not be interfered with until suppuration becomes well established.
There arc two periods when we will experience difficulty in
removing the plug; when we try to do so at too early a period,
Ml: \l \» n \M \i: \. On I
before suppuration has been eel up, or when ire allow them to
remain for ton long a time, when u«- prill find, at the result, that
granulations of Luxuriant growth will haw sprung up, and struck
i into the plug, thui establishing firm connexions between the
foreign body and the Schneiderian membrane, which can onh I"*
severed with considerable difficulty, a proceeding frequently attended
with no trifling hemorrhage. Mr. Smyly, tin- respected Benior Burgeon
to the Meath Hospital, informs me that he once Ban the late
Professor Macnamara experience considerable difficulty in removing
a plug thai had been permitted, by the Burgeon who had inserted
it, to remain an undue time without taking steps to remove it. If,
on the occurrence of suppuration, the surgeon proceed to remove the
plug, it- extraction will be accomplished with facility and safety^ for
now there will be no danger of a recurrence of the epistaxis.
Authors on epistaxis write of this operation for plugging the
posterior nares as if it were one of the most harmless in the entire
range of surgery. In my opinion it is an operation that only Bhould
be had recourse to under the gravest circumstances, when every
other method of arresting the flow of blood has been put in force
and failed; when, in fact, it becomes a question with the surgeon
whether to have recourse to it, or submit to the loss of his patient.
Why I entertain this opinion I shall now briefly state. In the first
place, even when most expertly and successfully performed, it is a
proceeding most repugnant to the patient's feelings, and most
incompatible with his comfort; the malaise that attends it is very
considerable, the sufferer being, the whole time that the posterior
nares are plugged, compelled to breathe through his mouth, which
enforces an open and consequently a dried up, parched, condition
of that organ: the sensation of the foreign body in this situation is
indescribably unpleasant, so much so that we frequently experience
considerable difficulty in inducing our patients to submit to it for
the necessary length of time. Still, were this all, I should not
write in such strong terms of disapprobation. But it is not all.
Mr. Fleming informs me that the late Professor Colles entertained
a very decided objection to this operation, founded on the fact of
his having been called in to see a patient in whom tetanus ensued
on this trifling operation, and which this distinguished surgeon
attributed alone to the presence of the plug, acting as a foreign
body, in the posterior nares. Nor is this the only and most serious
danger ; a very slight cause may loosen and detach from its position
the plug in the posterior nares, when it will fall down upon the
Mi;. M.\( \\m\ka on Epietaaris. 59
epiglottis, and produce almost immediate death. In such an
occurrence as this it is that the value of the piece of twine coming
out through the patient's mouth will be recognized; in such an
event it can al once be seized by n bystander, or by the patient
himself, the plug instantly be withdrawn, and the patient thus
preserved Brom certain immediate death. In the article on epistaoris
in CostelMa Practical Surgery, I find the able writer deprecating
the employment of this string, although, in a subsequent portion of
the same article, he alludes to this danger, and gives a case on the
authority of M. Martin St. Ange, where a fatal result, consequent
on this very accident, occurred in the medical wards of the Hotel
I Heu. The late Professor Porter informed me of the occurrence of
a similar accident, which terminated fatally, in this city, whilst he
was a student: and whilst I myself was serving my time in the
Meath Hospital to the late Sir Philip Crampton, I witnessed, in a
patient whose posterior nares had been plugged by the late Mr.
Bynd, a similar occurrence, when the patient's life was only saved
by the greatest promptitude, and where I experienced the greatest
difficulty in removing the plug from its perilous situation, because
of the non-presence of this, in my opinion, most necessary string.
The accident, most fortunately, occurred during the late Mr
Porters visit to the ward, when, of course, plenty of assistance was
at hand. Had it occurred at any other period of the day, the result,
in all probability, would have been far different, as, I need scarcely
say, that the patient himself was physically debarred from describing
what had occurred. In addition to these grave evils, I have seen
erysipelas of the face subsequent to and consequent on the plugging
of the anterior nares, and very frequently I have witnessed a most
unpleasant ozaena persistent for some weeks after the plugs have
been removed. Fortified with such experience, then, is it, that I
feel myself justified in asserting, that plugging the posterior nares
should be the surgeon's " last appeal."
In the article on epistaxis in Costelloes Encyclopedia, to which I
have already referred, I find it stated, on the authority of Blumen-
bach, that this disease is confined to the human subject. Beino-
aware that such a statement did not invariably hold true, so far as
the horse was concerned, I was anxious to ascertain whether, by
experience, he could be supported in that statement by gentlemen
who had made the diseases of this animal their special study. I
therefore addressed some inquiries on the subject to Mr. Doyle of
this city, the eminent veterinary surgeon, and received from him
Mi: Dayies on Radical Cure of Hern
the following interesting Letter, which, 10 far si the 1"
decides the point: —
•• 16, \\ ■ -tland-row.
\1 \ de vu Doc mi;,- In reply to your question aa to the occur-
ice of epistaxis in the Lower class of animals, 1 have to inform]
that 1 have repeatedly seen it to occur in horses. For example! in
Mr. Denis1 Albatross running for the Corinthians at the Curragh,
i wrv severe attack of epistaxis occurred, which, with some
difficulty, 1 was fortunate enough to arrest. Running for the
Liverpool Steeple Chase she had a second attack, which terminated
fatally. Also in a horse the property of Mr. Heathcote, 11th
Hussars, epistaxis took place whilst out hunting this season, which
proved fatal; and in many other cases also that came under my
own observation. 1 may mention, that plugging the nans with tow
steeped in vinegar has proved the most effectual remedy in my
hands. — Faithfully yours,
"Joseph Doyle, V\S."
In concluding these observations, it can scarcely be necessary for
me to remark that the subsequent treatment of every case of
epistaxis will require care and judgment on the part of the practi-
tioner. To enter on this topic, however, would be to open for
observation almost the entire range of disease. In the commen
nient of this paper I have pointed out the varied sources to which
it may he traced. These will all require consideration on the
part of the surgeon, who should always bear in mind that epistaxis
is far more frequently a symptom than a disease, and as such we
are bound to search for the " origo mali," and seek then to apply
our remedy.
Art. III. — Radical Cure of Reducible Hernia. By Kedfekn
Da vies, M.R.C.S., Birmingham.
SiXCE October, 1859, I have adopted, almost exclusively, for the
radical cure of hernia, the method devised by Mr, Wood, and
after finding, from the results of upwards of fifty operations, that
it is the most successful and least painful plan known, I most un-
qualifiedly prefer it.
The way I perform the Operation is as follows: — The patient
lying on his back, and his bowrels having been that day opened,
Mr. Davies on Radical Cure of Hernia. 61
chloroform is administered if wished f'<>r. An incision, one inch and
a-half below the spine of the pubes, is then made for abpul three-
quarters of an inch, the integument of tli«' scrotum only being cut
through; the lips of the incision are now successively seized hold
of, and by a blunt-pointed pair of scissors a dissection is made
beneath the integument, for a space of 1 wo inches around the external
opening of the inguinal canal.
The conjoined tendon is now to be fell for by the finger of the left
hand, which pushes before it some fascia. The needle recommended
by Mr. Wood is then carried on the finger to the externa] abdominal
ring, through which it is to be passed for a distance of about half an
inch, or it is thrust through all the soft parts above. \V hen the point
has emerged through the integument, the needle is threaded by a
Bilver wire, and then withdrawn with the wire. The first and most
difficult portion of the passing the wire is then accomplished.
The finger now seeks for the external pillar of the ring, and on it
the needle, bearing a loop of the wire already introduced (t. <?., the
wire simply bent on itself), is carried about half an inch within
the canal, and all the soft parts above it are transfixed. The ex-
tremity of the needle appears on the surface of the abdomen, bearing
a loop of wire, and it easily glides down the free end of the wire
when the loop is held.
And again, upon the finger having found the internal pillar, the
needle bearing the wire is carried and made to pierce the tissues
above, and a little within the canal. The needle having been
di -engaged from the wire is lastly withdrawn.
The free extremities of the wire are then passed through an
aperture in an oval piece of thickish glass (three inches long by two
broad), and the loop through another aperture a quarter of an inch
distant, and having been pulled together as close as can be, they
are twisted over each other, which securely fastens them.
The testicles having been supported by some tow, and the parts
washed, all is done.
During the day of operation some varicocele appears, which
depends upon the veins of the cord being pressed upon by the
disturbance of the parts and the consequent swelling, and remaining
but for a few days, indicates only that the operation has been
efficiently done, and requires no notice to be taken of it.
The loss of blood during the operation amounts to about half a
tea-spoonful.
The wires may be unfastened on the eighth day, and removed
Ml; DAVIE8 On / ' i 1 1, i
entirely on the next The puncture* and incision from which lomc
pus will exude, should In- treated bj prater dressing; ami when
healed (in about one week's time), the patient may be allowed to
up, and is perfectly cured.
The propriety of applying a Bpica bandage and compress, is now
a very 1 1 1 li*.- 1 l debated point We know thai continued pressure
induces absorption, bo thai il is reasonable t<> infer that the constant
pressure of a Bpica bandage and compress, will bo act upon the
recently introduced tissues in the inguinal canal and ring, and t hut,
eventually, there will be produced as bad a state of things as there
was before any operation was attempted.
However, practically, such is m»t the case In my former opera-
tions (those after Wutzer's method) I used the bandage with a
graduated compress, most extensively, and though not perfectly
satisfied with it, I did not find those effects produced, which
might have been expected from a theoretical consideration before
hand.
Believing, however, that for a time the abdominal walls must be
weaker in the inguinal region than elsewhere, and that concussions
had better be guarded against, 1 now use a simple bandage, and by
this means, cover in firmly the whole of the lower half of the
abdomen.
The rationale upon which this operation acts, is, I believe, as
follows: — A portion of fascia having been freed from its adjacent
parts is, by means of the wire, fixed in the canal and rings, so as
Mk. Daviks on l\<ulic(il ('///■<■ of Hernia. 63
to form a plug which prevents the gut, &c., from escaping out of
the abdomen. By this means, it acts in just the same way as
W'iit/cr's operatiou docs; and the only difference between them Ls
that, in Wiit/.cr's, union is at templed between two tissues which
were not intended by nature to unite; and in Wood.-, part- arc
united (and thai Bubcutaneouslj ) wliich are accustomed to he so,
naturally. Again, the rings, &C., instead of being forcibly dis-
tended, as in WiitzcrV method, arc made of Lesfl -ize, by having
their pillars, &c., drawn (irmly together; and kept so, by becoming
united with the fascia drawn into them.
Wood's operation may be looked upon as simply gliding into
another place, tissues which have a natural affinity one for another;
and by this means, causing a canal, &c., which has become distended
by pressure, to recover its natural calibre.
The reasons that have led me to prefer this operation, &c, to
WiitzerV, even with the improved instrument I have invented,
arc: — Firstly, its immense superiority, as founded upon the practical
observation of more than fifty cases upon which I have operated in
this way. Secondly, by the consideration, that a wooden plug (even
with the addition of a movable lower portion), can never adapt
itself to the tissues like soft parts. And thirdly, that there is, and
must be, great difficulty in inducing two surfaces to unite one with
another, which were never intended to do so by nature, viz., the
causing two layers of invaginated scrotal integument to adhere
together.
The improved instrument above alluded to, I have already
described elsewhere; but I now again figure and describe it.
Where Wutzer's operation is adopted, in cases of scrotal and
femoral hernia, with the tissues relaxed and the rings of large
size — say capable of admitting two, three, or more fingers — consi-
derable difficulty and disappointment is experienced in endeavouring
to effect a cure by one operation ; and it has occasionally happened
to others, and to myself, to be obliged to repeat the process.
From practical acquaintance with the subject on the living, and
repeated trials and experiments upon the bodies of the dead, who
have been affected with hernia, I have been led to believe, that the
cause of such failures is not attributable to any fault in the theory
of the method, but to a defect in the instrument; and upon the
following grounds, submit to the decision of practical test, that they
would be obviated by the adoption of the accompanying mechanical
improvements.
Mr. Davies
rupture in which the operation for
Ileal cure has failed (supposing, of course, t hut it bai been |
U managed, together with the proper after-treatment), th< ri
I the canal will be found to be obliterated, probably to some
three-fourths of their extent, or there ma\ be only an aperture which
will, with difficulty, admit a crow's quill; and thus, though the
patient may be greatly benefitted, and with the aid of a truss,
resume his duties, a radical <-m-< has not been effected.
That portion of the canal ami rings which have been blocked up,
i- invariably, that which i- aearest the abdominal wall-. " The gut
>lips down behind the plug," arc the term- in which, both surgi
and patients express the mishap which has occurred, and the reasons
for this me I believe, as follows: — The anterior or superior layer of
the invaginated integument, is subjected to, not only the pressure
of the wooden pine,- in Wutzer's instrument, to keep it in appo-
sition with the opposed surface of the canal and rings, but also to
the direct pressure of the compressor. The compressor exerts it-
influence exclusively upon the part- included between it and the
upper surface of the said wooden plug, and in no wise affects the
posterior part-: — viz., the posterior Layer of invaginated integument,
and upper surface of the canal and ring, whose Bole chance of being
kept in apposition depends upon the accuracy with which the plug
lits the canal, &c, a- a whole.
The floor oi' the canal, &C., especially where the tissues arc lax,
generally occurs in old and large rupture-, doe- not present in
the same manner an opposing resistance to the wooden plug as d
the compressor; and thus, should the two former he not very
accurately adapted the one to the other, adhesion cannot even he
expected to occur.
The mouth or internal opening of the canal, is funnel-shaped,
with the posterior surface the more sloped; consequently, if there
he a weak point it will he there, and it i- sure to receive all the
shocks of the irut during the process of cure.
Besides, it i- evident that a cylinder, even closely applied to the
rest of the extent of the canal, cannot till up its funnel-shaped
mouth; hut must have an interspace which will be on the posterior
surface.
And asrain, it is not always practicable to introduce to a sufficient
extent, a solid plug, which would best lit the internal ring, on
account of the resistance of the other tissues to its passage ; besides
entailing an endless variety of such plugs.
Mb. Da vies on Radical Cure of Hernia
65
By the adoption, however, of the principle I now propose, viz.,
a plug, whose lower half is capable of expanding, those difficulties
are severally o\ ercome.
A glance at the diagram will render its application at once
evident; it will be seen by turning the handle of the dilating
screw, and thus causing the lower half of the instrument to expand,
that the pressure upon the parts included between the upper por-
tion of the plug and the compressor, is left in exactly the same
relations and conditions as in the usual instrument; but, that a
force is exerted upon the posterior portion of the invaginated inte-
gument, canal, and rings, which it gently, but firmly, retains in
complete apposition one with the other.
By reason of the greatest point of its expansion being at the
extremity of the instrument and gradually tapering, two objects are
accomplished ; first, the funnel-shaped mouth and the internal open-
ing is filled with a plug, whose sides are inclined towards its own —
the invaginated integument being, as it were, modelled upon it;
and secondly, the rest of the canal is, at the same time, subjected to
no undue pressure.
The principle adopted by Mr. Spencer AVells, is likewise, made
available, viz., having the transverse diameter of the instrument
much greater than the antero posterior, whereby the shape of the
ring is altered, it being converted into a mere chink, and thus
affording an additional security against the descent of the gut ; and
so leaving as small an amount of space as possible between the
opposed surfaces of the doigt de gant to fill up when the instrument
is removed. A thin India-rubber finger-stall caps the end of the
instrument preventing any soft parts getting between the blade-.
With regard to the metallic uprights and screws, they are so
VOL. XXXIII., no. 65, x. s. r
I » \ . I .
Arranged thai the amount of pressure I bj the oomp
in;i\ be applied just b , an e be preci
thrown, when desired, upon the pari pierced by the needle, or u]
the edge of the euh bj alternating the screws; or a genera]
and equal pressure may be exercised upon all the part* included
between the compressor and the plug.
With regard to die permanency of the cure effected:— -The
first case 1 did, and which is reported in the Medical Times, June
12, 1858, remaini -till well on one tide, and has done so ever
since he was operated upon, then being received into tin* police
force. Several men have entered the army ; and I always ask people
upon whom I have operated, how- they arc when i see them again
(which in a workhouse practice — tramp-, &C. — was very frequent),
and 1 am invariably told, that their oases -till remain perfect.
Some few cases, however, 1 know- of as having relapsed.
I have operated, by the subcutaneous method, upon upward
fifty cases, and have tailed to cure but five cases. In one of these
the person, who was not of Strong mind, made, at the time of with-
drawing the wire, such a struggling and disturbance, from fear that
he should be hurt, that, as 1 told him at the time, the operation WM
a failure, for, by his movements he forced the gut down. In the other
oases 1 know of no probable solution to account for the failure. In
one ease where the rings, &C., admitted three fingers breadth-ways,
a second operation was found necessary.
I have never seen the least danger or pain in any one case, con-
sequent upon the operation. In some hard-lived men, bronchitis
and flatulence, chiefly the result of assuming the recumbent posture,
came on, and were easily relieved by the ordinary medicines.
From frequent and careful dissection of the parts, I had been
induced to believe that the peritoneum is not touched in this opera-
tion; and the same opinion has been verified by a post mortem
examination of the parts, some four months after the cure had been
effected— the patient dying from fever.
In one case, occurring in the practice of Mr. Harding, of Stour-
bridge, upon whom I operated, the patient leaving refused chloro-
form, became so unruly during the operation, that he seized my
hands several times whilst I was passing the needle; upon being
told that if he did so again I should be compelled to leave, he
became rather quiet and did not again seize my hands. In the
night of the same day, Mr. Harding was sent for to him, and found
him labouring under an acute attack of peritonitis; he instantly
Keyfeldeb on Resection or i',rtlrp<iti<m of tl><> Astragalus. 67
took off everything; and in the morning sent me word — upon
arriving at the house I found he had died. No post mortem exami-
nation was allowed.
Akt. IV. — Complete Resection or Extirpation of the Astragalus.
By Dr. Oscar I1i:yfelder, of St. Petersburg.
Since I published my book treating the resections of bones and
articulations, two cases of extirpation of the astragalus occurred to
me which I think worth communicating.
Case I. — Ivan Terasimof, 30 years old, coachman, received a
semi-luxation of the astragalus by a heavy butt falling upon the
back of the extended and fixed right foot. No wound of the skin,
but a very considerable swelling of the ankle. Received into the
hospital for workmen: the inflammation and swelling yielded to
an antiphlogistic treatment; but the skin of the back of the foot
where it was over-extended by the luxated astragalus, became gan-
grenous, and the foot remained in the position of extension, the
ankle joint being incapable of any movement. After some weeks,
not only this state remained, but a fistula had formed itself on the
inside of the foot, corresponding to the anterior and exterior parts of
the astragalus, where a probe might be introduced into the softened
osseous tissue, and easily made to penetrate even to the skin at the
exterior side of the foot. The dislocation of the astragalus being an
irreducible one, and the osseous tissue being even carious, I proposed
the extirpation of the dislocated bone ; the more so as this operation,
in 63 previously recorded cases, had given very good success.
The 28th of September, 1860, I proceeded to the operation. A
curved incision, the convexity towards the toes, divided only the
skin, and permitted me to separate the skin from the subjacent
tissue, to separate the well conserved extensor tendons, and put
them aside. The dislocated astragalus being pressed into the tissue
of the cuboid bone, and firmly retained by the posterior and inferior
ligaments, it could not be removed but with much difficulty, and
by dividing the tendons of the extensor digitorum longus. The
astragalus being extirpated, and the morbid parts of the cuboid
being removed by help of a gouge, I joined the wound with silver
sutures, fixed the foot upon a splint, and laid it in a warm water bath.
v -1
11 i.\ i i.i i»i i: on R I tirpation of the A
30th September.-— The pain- of the wound very tolerable in
nparison with what be had Buffered before Suppuration good;
the whole Btate very ictory. On the 8th October the Butm
irere removed, and almost the whole incision found closed by the
fust intention. The movement of tl: rerj easy, and not at
all painful. In this, as in other eases, the MCOndary operation, in
comparison with primary ones, has proved preferable, by the Blight
degree of reaction, and, in general, by the easiness with which this
was supported.
When the permanent bath ceased to be agreeable to the patient
(about the 14th day), the limb was put in a dry bandage, and, from
time to time, movements were undertaken. He received a corro-
borating diet, and went on pretty well; when, three weeks after the
operation, the foot was taken with erysipelas, which is almost endemic
in that hospital.
A fortnight after his restitution, when the movement of the toes,
and even of the ankle joint, had been established, hospital gangrene
broke out in the wards, with which he was very dangerously affected.
Our usual remedy, cataplasms of grated carrots, and the internal
use of decoction of cinchona with aromatic tincture and acids, restored
the man, after that even amputation had been taken into con-
sideration. From the seventh week the convalescence went on
without further interruption. Active and passive movements took
place every day; and with the beginning of December the first
i --ays of walking could be made without much pain or difficulty.
The 26th December the man left the hospital, quite restored
to health, his foot being cured. The wounds closed; position and
movement normal; no deformity; the shortening of the limb
l^cm. (six-tenths of an English inch); the sole something flat; the
back of the foot of a quite normal form ; sensibility, temperature,
and the colour of the skin like that of the other foot.
Case II. — Ludwig Susemuhl, 14 years old, baker, of a delicate
complexion, fell, in the beginning of the month of October, 18(30,
and got a distortio in artieulo pedis, whose consequences had not
yet quite disappeared, when he fell a second time, and hurt the
same ankle joint in a very painful way. When he entered the
hospital for workmen, on the 10th November, we found an irreducible
dislocation, a considerable swelling of the foot, great painfulness,
which increased by touching or movement; inability to walk.
Twenty leeches, and fomentations with aqua saturnina could only
Heyfeldeb on Rssection or Extirpation of the Astragalus. (>i>
allay the pains and Inflammation, hut not change the general state
of the foot; nor could the local application of unguents, and the
internal employment of nit rate of soda cure the symptoms of a loeal
chronic inflammation and a general state of fever. Abscesses, which
formed on the inner side of the ankle joint during the month of
December, were opened, and gave issue to a laudable pus. They
corresponded to a rough, carious, and softened part of the astragalus.
The whole hone proving carious, and the neighbouring bones being
intact, I proceeded, on the 28th December, to the removal of the
diseased astragalus. As I believe it of great importance in all
resections that the wound of the skin should coincide as little as
possible with the defect in the bones (the former should be as far as
possible from the latter), I made a real gaiter like incision (like that
of Baudens for the exarticulation of the ankle joint). Continuing,
as in the former case, and finding the bone not as firmly attached,
I succeeded in keeping sound all the extensor tendons, and in
removing the bone in two halves. The tendons being isolated, and
kept aside, I introduced the chain-saw, and divided the astragalus
in an oblique line. No blood vessel being to tie, I adopted the
same bandage and treatment as in the former case. The local suc-
cess being almost as good as after the first operation, the symptoms
of tuberculosis pulmonum et intestinorum showed themselves more
and more ; the wound got gangrenous ; and in the end of January
he died with phthisis generalis. The post mortem examination
proved lungs and bowels covered with tuberculous deposits, and the
wound of the foot filled with unhealthy pus, notwithstanding its
partial reunion.
If we add these two cases to the rest, the operation has been done
in 78 cases, since the year 1670, when Fabricius Hildanus per-
formed it for the first time. After him it has been executed by
Broglie, Aubray, Ferrand, Desault (five times), Manduyt, Lau-
monier, Rumsey, Trye, Hey, Charley, Daniel, Percy, Roux,
Dupuytren (four times), Evans, Green, Lynn, A. Cooper (twice),
West, Stevens, Follot, Nowood, Cloquet, Arnott, Thierry, Norris,
Heidenreich, Hinterberger, Rognetta, Dietz, Quetalet, Velpeau
(twice), Robert, Wackley, Chabanon, Thore, Letenneur (twice),
Statham, Estevenet, Hancock, Addenbrock, Smith (eight times),
T. F. Hcyfelder (twice), Chassaignac (twice), Gisborne, Husband,
and the Author (twice). Partial resections have been made by
Moreau (the father), Duverney, Rattley, Champion, and another
English surgeon whose name I do not know. So that five out of
! 1 1. \i i i.iM.i; on Resectioi \tionofthi Astragalu
artial — 73 total; 11 of the 78 operated on d lived
operated on, vrhose lives wett pn I two irere aft
irardi iubjected to amputation— one for deformity and asel<
of the member; 05 were fully restored. The fetal form, o
[uently, one-seventh, the unsuccessful ones one-sixth of the total
number.
Ankylosis of the ankle joint is not at all, u Boyer pretends, the
oea consequence of the operation; as, out of the 07 successful
oases (which generally are not even extensively enough commu-
nicated) I found lo in which the movablenese of the foot, or even
the formation of a new articulation was established and expressly
named. Ankylosis may, of OOUTSe, take place by very aeute
inflammation, by want of passive and active movements, or by
retraction of extensive cicatrisation, as it happened in one of Chas-
saignac's eases.
The indications for this operation are exceptionally caries or
necrosis; usually traumatic injuries (01) times out of 78), tin
may be gunshot wounds, or fractures, or complicated luxations; the
latter are the most frequent cause for the extirpation or resection of
the astragalus ; 08 out of 78 cases were operated on for this reason.
Not only luxations complicated with fracture (twice out of 08 times ).
with wounds, with secondary disease of the bone, but even fresh and
simple luxations, which cannot at all, or not without much difficulty
and power be reduced, should rather indicate the partial or total
resection, as Dupuytren (Annuaire Med. His. ties Hop. de Pari*,
1819, p. 28) did in one case with full success. On the contrary, I
believe that in my second case, and in one observed by Professor
Bruns (Deutsche Klinik, 1857, pp. 479, 480), where the man died
without having been operated on, an early resection of the astra-
galus might have saved the life.
Mi;. Wilde on Malformations, <y<\. of the Organs of Sight 71
Akt. V. — An Essay upon ihs Malformations and Congenital
Diseases of the Organs of Sight. By W. K. Wilde, M.D.,
V.P.R.I.A., F.R.C.S., Surgeon to St. Mark's Ophthalmic II<»>-
pital, Honorary Member of the Medical Society of Stockholm,
&c.,&c With Illustrations. Part IV.
(Concluded from vol. \x.\i. p. 71.)
MAI.FOIi.MA 1 IONS OF THE VITBEOUS BODY, RETINA, AND OPTIC
NEKVE.
Having already described the formative process in the human eye,
it is unnecessary to enter at any length upon the peculiarities in
the mode of growth in the retina. Within the last two years V.
Amnion published a memoir on the Embryology of the Eye, in the
Archiv f&r Opthalmologie* in which he says the retina appears, in
the fourth or fifth week, as a white downy membrane in contact
with the lens, open behind and on one side. In some very rare
cases of development this retinal fissure remains permanent, an
instance of which is given by that author in his previously published
work, the Klinisclie Darstellungen der Angebornen Krankheiten,
Bd. iii., Taf. xi., Fig. xv. From the middle of the third to the
middle of the fourth month, the retina resembles brain — white and
thick, and filling up the space between the choroid membrane and
vitreous body. About that period a ridge or projection, like the
pecten in birds, passes in through the slit in the retina to a sulcus
in the vitreous structure ; but this in time is absorbed. During the
fourth and fifth month, convolutions like those seen on the surface
of the brain are observed on the retina, and are not altogether lost
till the eighth month. A few of these folds may, in some cases, be
seen in the site of the fissure, even up to the ninth month ; and V.
Amnion says that the persistence of this embryonic condition, in the
slightest degree, impairs vision. In the second month, nerve-cells
and granules are recognisable, and in the third and beginning of
the fourth the ora serrata is discernible; but the optic nerves do
not appear till about the end of the third month. When the brain
and eye-cells, originally in contact and communication, become
separated by the orbital plate of the frontal bone, the optic nerve is
developed in the form of a fissure or gutter, which is afterwards
* See review thereof in the August number of this Journal, vol. xxxii., p. 127.
\I r \\ i i.i»: on Malfo nd
closed along its length, and filled with nerve mattei The retina
and optic nerve are joined towards the end of the third month; and
in the fifth, tin arteria centralis, which hai been formed very earl)
in tirtal life, dwindle*. Any interference with the foregoing pi
must result in malformation, or congenital discs
Besides tin- cases mentioned above, dissections have been given
of club-shaped retinas, each of which presented a pyriform ma
lying between the ocular end of the optic nerve and the lens In
other instances, it is said that there was over-constriction of the
optic nerve at the cribriform plate.
In cases of microphthalmos, and other manifest alteration- and
arrests of development in the eye, there is generally evidence of
deficiency of formation in the vitreous body or retina, but careful
dissections of such have been rarelv recorded
CYCLOPIA.
Monstrosities in which there is but one apparent eye are not
unusual in the human subject, and are also seen in the lower
animals, especially lambs, kittens, and calves. In nearly every
instance the tutus is acephalous. Where only one eye exists, but
retains its natural position, the ease maybe termed monooulus; and
where the eve is misplaced, it may be called a eyclops. In this
latter condition, although there is apparently but one eye, it consists
of two globes fused together, and there are either three or four
eyelids.
From Dr. May lie's able article on the Optic Nerves, in Todd's
Cyclopaedia of Anatomy and Physiology, I extract the following
passages : —
•• A single eye placed in the middle line of the forehead, and in
general a trunk or proboscis growing immediately above this solitary
organ of vision, constitute the most striking apparent anomalies in
monsters of this class. The fundamental defect in these monstrous
foetuses consists in the total absenee of the organ of smell, in con-
sequence of which deficiency the symmetrical organs at either side
become united in the middle line, and actually engrafted upon each
other; the two eyes are conjoined so as to form but a single organ
of vision, and the very same metamorphosis occurs in the two orbits
the two optic foramina, the two optic nerves, &c. That this is the
rationale can scarcely admit of a doubt, since in some parts of the
organs the fusion remains incomplete ; thus two crystalline lenses
Congenital Disi >'//>< Organs of Sight.
7:;
still exist in the interior of the solitary eye-ball; a double set of
muscles, with their corresponding nerves, are provided for the globe
of the eve; and four eve-lid.- protect the organ in front, Causingthe
aperture of the lids to assume a quadrangular form."
One of the most remarkable instances of monoculus, or a single
c\ e in its normal position, occurred in the I )nl»lin Lying-in Hospital,
about fifteen years ago, and from the recent specimen of which case I
had the accompanying illustration made. The foetus had nearly
arrived at the full period; one side of the head and a large portion
of the faee were deficient, and the parts were there attached to the
shoulder, as shown in the engraving. The preparation still exists
in the Museum of the Lying-in Hospital.
PLURALITY OF EYES.
This peculiar form of malformation, to which may be given the
name of polyoculi has not heretofore been mentioned by authors.
The accompanying illustration, from a drawing which I had made
many years ago, of a four-eyed monster, which occurred in the
Mi: \\ H.i'i. m Mal/ormai of the < Id.
Dublin L H ital, affords an example of tl<i~ verj rare
^formation rhia child was in other respecti well formed; but
the Upper portion of the head and face was double, all the parts
below the nostrils being fused into one.
Vrolik, of Amsterdam, who paid much attention to the subject
of Cyclopia, in 1834 and 1836, has divided this form of congenital
malformation into the varieties: — 1. Where the eve or eyes arc
not visible externally; in which there is a single orbit, with a slit
between some folds of Bkin, marking the site of the eyelids; the
orbital portion of the frontal bone generally absent, and no optic
nerves. 2. A single eye, visible externally. 3. A single sclerotic,
containing one or more of the internal parts in duplicate. With
this variety there is generally a snout-like nose. 4. The division
into two globes is more distinct than in the former ease. 5. The
eyes are double, partially or completely, but divided by a septum,
and there is a proboscis-like nose.
The state of the eyelids, from a mere slit to that of a triangle,
and finally a lozenge-shaped opening, depends upon the foregoing
1 >i;. Axthaub on Carbonic Acid in Mineral Wateri 7fl
condition ofthe globe. Il U manifest (hat (lie fusion of the eves in
cyclopia is a pathological condition consequent on an arrest of
development in other and adjacent parts; and the state of the cho-
roid and other internal structures depends on the greater or less
amount of fusion of the cornea and sclerotica.
Akt. VI. — On Carbonic Acid in Mineral Waters. By JULIUS
Altiiaus, M.D., Member ofthe Royal College of Physicians of
London, &c.
( Ki: of the most important and interesting constituents of mineral
waters is carbonic acid, the " spirit of the springs," which not only
greatly contributes to the solubility of certain salts contained in such
waters, but also renders them more palatable and more agreeable to
the stomach. It is especially important for chalybeate waters, which,
when devoid of carbonic acid, soon lose the iron which was in
solution, and also become heavy and unpalatable. There are some
very strong chalybeates in England, as, for instance, the springs of
Sandrock, in the Isle of Wight, those of Dorton, in Oxfordshire,
and those of Tunbridge, which, if they only contained carbonic acid
gas, WT>uld no doubt attract a large number of patients from this
and other countries, who now resort to the waters of Spa, Driburg,
Pyrmont, Schwalbach, and other continental places. The strongest
chalybeate known in the whole world is the Aqua Ferrata di Rio,
in the island of Elba ; but as it does not contain any carbonic acid,
it is entirely useless for medical purposes.
In mineral waters, carbonic acid is found in three different states.
It is either " bound" to certain bases, with which it forms carbonates ;
from these the gas does not escape, when the wrater is heated ; or it
is " half-bound" forming sesquicarbonates and bicarbonates, from
which compounds part of the gas is disengaged as soon as the water
comes in contact with the air, and still more rapidly when it is
heated ; so that, since certain salts are only soluble as bicarbonates,
and insoluble as carbonates, they are precipitated as soon as the
surplus atoms of carbonic acid are gone ; finally, it is contained in
the waters free, as gas, which escapes at the ordinary temperature,
as soon as the water rises out of the earth, and the pressure under
which it was in the interior ceases. This escape is more rapid and
powerful when the water is hot or artificially heated. Carbonic
I )i; Ai. i ii vi a an i ari I id in Mineral M
acid i- found almost entirely pun- in the neighbourhood of the Lake
!. ioh, in Weinberg, and Driburg, while in other plao it ii
found mixed with nitrogen, lulphuretted hydrogen, and oxygen
The tension with which tin- gas escapee, showi considerable
variations in the Beveml mineral waters. When there are many
outlets for it in a certain Locality the tension is, generally ipeaking, not
considerable; but if borings are made in places where there ha- been
no previous exit of gas, the pressure is sometimes bo powerful, that
as soon as an opening is made, it rises twenty or thirty feel into the
air, carrying with it large stones from the boring hole. This has
often been observed in boring for artesian wells. The Bame ii the
ease, if the escape of the gas 18 accidentally or intentionally impeded.
Thiis, some time ago, the tube connected with the acidulated spring
at Pyrmont, had become obstructed, whereupon the gas heaved
up not only the large metal funnel, which, at its upper end, is
eight feet in diameter, but also the whole cottage that had been built
over it.
The quantity of carbonic acid contained in the spas is very
variable. It is well known, that common spring water contain- a
certain amount of carbonic acid (from one-sixth to one-fourth of a
cubic inch in the pound). River water is also slightly impregnated
with this gas, and a little more of it is found in sea-water than in
fresh water. The small quantity contained in drinking water is
sufficient to impart to it a refreshing taste, which no water has that
is quite devoid of carbonic acid But the amount of this gas
contained in springs, rivers and the sea, is very trifling when
compared with the quantity found in certain spas. It varies from
one to seventy cubic inches in the pound, and such waters as
contain ten cubic inches or more are called acidulated springs.
The amount of carbonic acid found in mineral waters is dependent
upon several conditions, of which the chief arc, hydrostatic pressure,
and temperature. According to Lersch, one ounce of water at a
temperature of from about 40° to 60° Fahrenheit, absorbs at the
ordinary pressure of air, one grain of carbonic acid. If the pressure
increases, more gas is absorbed, but not in the same ratio, as by a
pressure equivalent to seven atmospheres, not seven, but only five
times the ordinary amount of gas is dissolved. As soon as this
pressure ceases, gas-bubbles are set free from the mineral spring, in
the same way as on opening a bottle of Champagne.
The escape of carbonic acid from the springs, is considerably
influenced by the variations of atmospheric pressure. When the
Dr. A i. thus on Carbonic Acid in Mineral Water*, 11
barometer rises, less <ras i- set free; l»iit if it falls, as, for instance,
before a Btorm, the amount of gas evolved is very large, 1 1 i * * bubbles
rise more rapidly, the Burface of the springs appears more agitated
than usual, the water has a more refreshing taste, and, where hat lis
of this gas are given, the bathers find it impossible to hear the
powerful effects of it ; a Circumstance which has been more especially
noticed by M Bertrand, in the gas-baths of the Auvcrgne. The
carbonic acid discharged by the Etacoczi of Kissingen, varies, according
to the atmospheric pressure, from 110 to 170 cubic inches of pis in a
minute. These gas springs may, therefore, serve as indicators of an
impending change in the weather, and only seldom deceive the
observer. In consequence of a diminished amount of gas in some
Springs, oxide of iron, which is only kept in solution by carbonic
acid, is precipitated, and imparts to the water a red colour, which
mostly indicates the approach of heavy rains. It is from such and
similar natural phenomena that weather-wise persons draw their
prophecies.
The temperature of the water has also an important bearing upon
the amount of carbonic acid contained in it. The capability of
water to absorb carbonic acid, decreases in an inverse proportion to
its temperature. Accurate calculations have shown, that 1,000
volumes of water will, when heated from 40° to boiling point,
expand to 1,043 volumes, while 1,095 volumes of carbonic acid,
which are absorbed by 1,000 volumes of water, expand to 1,417
volumes ; therefore, if acidulated water is heated, the gas expands
much more largely than the water, and for this reason alone part of
it must escape. But there are other influences at work, which carry
off a still larger quantity of gas from heated water, namely, the
diminution of affinity which exists between hot water and other
gases, but its own ; the more steam there is present in water, the
less of foreign gases can be kept in solution; besides, the steam
bubbles, which rise from water when heated, mechanically carry the
carbonic acid away with them. At boiling point carbonic acid is
entirely expelled, as are in fact all foreign gases; but gentle heat is
not sufficient to drive the gas entirely out. Thus water used for
bathing, at a temperature of 86° to 88° Fahrenheit, may still be so
much saturated with the gas, that, if the patients enter the tubs, the
whole surface of the body becomes thickly covered with bubbles of
carbonic acid, and if wiped off they immediately re-appear. A low
temperature enables the springs to retain a large quantity of carbonic
acid, and; consequently, to keep in solution a comparatively larger
|)u Ai.iiim ' '
<piantit\ of the carbonate of lime Mid m dde of iron, arid
other substances which are insoluble in the absence of thi If
tin.' latter escapes, the salts just named arc at once precipitated
The more or less intimate connexion of carbonic acid with certain
mineral waters, has been the subject of much mystical misrepresen-
tation. Thus it was observed that, the gai is more loosely bound
to the acidulated springe of Silesia than to those of Pyrmont, Spa,
Seltzers, and Driburg; that the g med only to travel throa
ae of the Bprings, while other- were very firmly impregnated
with it; and such and similar observations were adduced to prove
that physical laws wot not sufficient for explaining the wonderful
phenomena connected with the " spirit of the spring But if we
analyse the actual state of things, it is not difficult to account for
it in a scientific manner. Thus, for instance, we should naturally
expect that the water of Reinerz, in Silesia, would lose its carbonic
acid sooner than that of Driburg, in Westphalia, as the former has
a temperature of 66°, and the latter of 51° only. But it is true that
the temperature and pressure are not in all cases sufficient to account
for the more or less intimate connexion of carbonic acid with water;
in such instances, however, we can always trace other physical or
chemical influences at work. Thus, if water saturated with a certain
gas, conies in contact with other gases which it does not yet contain,
it will dissolve a certain amount of these latter; but, with the toes
of a certain quantity of the former. If water, which, when rising
from the earth, contains no other gas than carbonic acid, comes
in contact with the atmosphere, it at once absorbs nitrogen and
fgen, whereby carbonic acid is driven out; but when water is
already impregnated with nitrogen and oxygen, before it rifi
carbonic acid will be the more firmly bound to it. Finally, we
have to consider that water keeps gases less easily in solution, in
proportion to the increase of its own specific gravity. Carbonic
acid, therefore, escapes more rapidly from strongly concentrated
saline waters than from such as contain only a small quantity of
solid ingredients. If these circumstances are borne in mind, we
shall almost always be able to explain the relations of carbonic acid to
water, ami may, in fact, often determine, <) priori, whether a certain
spa is likely to contain much or little of this gas. Thus, for
instance, the brines and bitter waters which contain from 80 to
2,000 grains of salines in the pound of water, will not contain much
carbonic acid; the bitter water of Friedrichshall, in which 193
grains of salines are dissolved, does not contain. any carbonic acid.
Db. Altiiai 8 on Carbonic AM in Mineral Waters. 79
Thermal springs will also contain wry little of it, on account of
their high temperature, while such waters as are rather cold and
contain only B moderate quantity of -alines, present the most
favourable conditions for absorbing a large amount of this gas, and
keeping it in solution for a considerable time. In some spas it is
contained in such Large quantities that it constitutes their chief
element; while in others carbonic acid is not the characteristic
feature of the water, although it essentially modifies the composition
and the effects of the Bame.
The BOUrces from which mineral waters derive carbonic acid are
of various kinds, and where they are abundant, waters which have
a high specilic gravity mid a comparatively high temperature may
contain more gas than others of, perhaps, less gravity and tempera-
ture, but which are in a neighbourhood where the sources of it are
sparing. Small quantities of carbonic acid are absorbed by the
springs from the upper strata of the earth, which attract it from the
atmosphere, and in which it also accumulates by putrefaction of
organic bodies. Fossil remains of plants contain a large amount of
carbonaceous matter ; and if water runs through such strata their
substance is decomposed by the oxygen, which is always present in
it ; and thus carbonic acid is formed, which is then generally found
together with sulphuretted hydrogen. That free oxygen is lost in
this way, and oxygenation of carbon takes place, is evidenced by the
circumstance that common spring wrater contains less oxygen than
rain water (respectively 16 and 7 volumes of it in 1,000 volumes of
wrater).
But the sources of carbonic acid I have just enumerated only
hold good for a limited number of acidulated springs, most of which
are, no doubt, connected with active or extinct volcanoes. Ex-
halations of carbonic acid, either in its free state as gas or united
with water, are generally the last remnants of Plutonic catastrophes.
The carbonic acid can at present only rise where disruptions of the
crust of the earth exist, and its upper strata do not offer an im-
pediment to the exit of the gas. Such rents we find, for instance,
in Germany, at Pyrmont, where the wrell-known Grotto of Dogs is
filled with pure carbonic acid; and powerfully acidulated chalybeate
springs issue from the fissures in perpendicular layers of sandstone.
Carbonic acid also rises from the basalt formation which Ave find
extending through Germany from the Eifel to the lliesengebirge.
In the neighbourhood of the Lake of Laach there are more than a
thousand acidulated spring to each other. In some of them
Di: Ai. i ii v i in Mineral H
tin- bubbles which escape from tin- water are as la the h-
ui adult, and a noi of hissing, whizzing, and is
heard at a greal distance. Within a few miles of Marienbad we
find 124 acidulated springs, and the quantity of carbonic arid
developed in them is something prodigious Prom an approximative
calculation the springs of Meinberg furnish aboul one million of
cubic feel annually, and those of Nauheim eleven millions. in
France we have exhalations of carbonic acid in the cave ofMontjoly,
in the Auvergne, and the Puits de Nerac, in the Vivaraia. In
ItaK we find the gas-springs of Sciacca and Latent, at the fool of
the Etna; the famous Grotto del Cane near Vesuvius; the Lake
of Amsanotus, near Naples, in which the carbonic acid is mixed
with sulphuretted hydrogen; and the Guada Afortale, in the
neighbourhood of that lake, which contains pure carbonic acid, and
where sheep, hares, and rabbits are often found suffocated. In
Greece there were and are still many places when' escapes of this
gas occur; such was the steaming cave in Apollo's Oracle at Delphi,
where the Pythia pronounced her prophecies, and of which no
remains are let'i ; also the gas-springs in the sacred forest of Dodona,
near Epirus, the most ancient oracle of the Greeks; the springs of
Thermopylae, and many others. The phenomena observed in such
places are so remarkable that we cannot he surprised at finding an
uneducated age and people Looking upon them as manifestations
of supernatural powers. In fact, the hissing- and gurgling sounds,
occasioned by the discharge of the gas, were, by the ancient-,
believed to he the voices of demons. It was in places like those
just mentioned, which were called the " spiracula Orci, " that,
according to Homer and Virgil, Odysseus and .Eneas went to the
Lower world to meet the spirits of the departed; that oracles were
founded which were used by a cunning priesthood to deceive the
vulsar: and it was into the awful lake of Amsanctus that, according
to Virgil, the fury Alecto, in her anger, precipitated herself from
the summit of the mountain.
Volcanic agency does not, however, produce earhonic acid; it
merely provides it with an outlet, tearing asunder the crust of the
earth, and taking away the obstruction to the i'wc escape of the gas
from the interior of the globe. The most abundant source of carbonic
acid is, no doubt, the decomposition of carbonates, such as the
carbonate of lime, of iron, of magnesia, which enter into the com-
position of the solid crust of the earth. The common limestone alone
exists in such quantities in it as to be able to give out inexhaustible
Di:. Thobp on Encysted Tumours. 81
Streams Of Carbonic acid from every point of the earth's surface, of
which this salt, together with silica, forma the greatest part; its
geognoBtica] distribution extending from the newest tertiary deposit
to the oldest primitive rocks. Prom its combination with lime,
carbonic acid is evolved partly l»\ sulphuric and hydrochloric acid-,
which exist in the interior of the earth, sulphate and chloride of
lime being thus formed; and partly l»\ a simple process of calcina-
tion which is continually carried on at a certain depth, in consequence
of the heat inherent to the interior. Berzelius believed that the
action of the heat, and, therefore, a continued evolution of carbonic
acid from Limestone, ceased at the depth of two or three fathoms
from the Burfece, in consequence of the very bad conducting power
of the .-tone. But Bischof has proved that if limestone is exposed to
a high degree of heat it cannot retain its cohesion and firmness; in
fact . under such circumstances, the rock soon cracks in every direction,
is disintegrated into fragments, and thereby affords ample room for
the continued influence of the heat, which is, of course, assisted by
the presence of a large amount of aqueous vapours. This is, only
on a larger scale, the very same process which we may every day
observe in our artificial lime-works.
In a subsequent communication I intend entering into the
physiological effects and the therapeutical action of carbonic acid,
both as gas and when dissolved in water.
Art. VII. — Observations on Encysted Tumours. By Henley
Thorp, M.D., F.R.C.S.L, L.K. & Q.C.P.I., Letterkenny.
During the last ten years I have been called on to operate upon
several cases of encysted tumours, and as my experience of these
growths, at least as they occur in the orbital region, does not cor-
respond in some respects with Mr. Hamilton's, as published in his
memoir in the last number of this journal, I am induced to give a
brief account of a few cases, out of many others, ivhich have come
under my notice, and to append a few remarks upon encysted tumours
generally, as well as upon those which occur in the neighbourhood
of the orbit in particular.
Case I. — In the summer of 1853, a farmer, aged 30, consulted
me respecting a swelling that occupied the outer part of the left
VOL. XXXIIL, NO. 05, N. S. G
Dil Thobp on Encysted Tumour
superciliary arch; it commenced a1 boyhood and enlarged ilowly,
oval in form, aboul the size of ;i iralnut, and pro down-
cupj the corresponding portion of tin- eye-lid; I
integuments vrere of a dusky-red colour from s remarkable increa
in the number and size of the cutaneous blood vessels; 'I"- skin
moved freely, but the tumour itself «*as evidently closely adhen
to the Bubjaoenl parts; it was also tense, and possessed s certain
degree of elasticity as irell as fluctuation. A transverse incision
through the skin and orbicularis, along the lower edge of th<
brow, exposed the swelling, which was, in the firs! instance, detached
from its connexions by a process of tearing and cutting — using
alternately the handle and blade of the scalpel— at length it was
found impossible, from the tumour's tenseness and size, to depress it
Sufficiently to permit of its separation from the orbital plate, to which
it closely adhered; a puncture obviated this difficulty, by emptying
the Bac, which in a collapsed condition was cautiously dissected from
its bony deep-seated attachments, and removed entire; the cyst was
thin, but strong, presenting internally a pearly lustre; the contents
were semifluid, viscid, and glairy; that portion of the superciliary
ridge upon which the tumour rested was rounded off, and presented
a blunt depression.
Case II. — James Dogherty, aged 22, a constabulary recruit.
There exists at the outer and upper part of the orbit a smooth
globular swelling, about the size of a pigeon's egg; it is situated so
as to lie for the most part on the frontal bone, but it entrenches
also on the upper lid ; the outer extremity of the brow crosses the
tumour below its centre; fluctuation is tolerably distinct ; the integu-
ments move freely over its surface, but it is evidently fixed to the
parts beneath; the lid, where it overlies the tumour, is of a purplish
red colour, but towards the temporal region the discolouration is not
so manifest. The patient states that the swelling has existed for
several years, but that its rate of growth has latterly very much
increased. The cyst was brought into view by a transverse incision
above the brow, and separated from its cutaneous connexions with
tolerable facility, when transfixion with a tenaculum enabled me to
free it from the periosteum, and dissect it out entire. The bone
presented a well-defined hollow, which interrupted the continuity
of the temporal ridge close to the external angular process. The
cyst contained a finely granular substance, of the consistence of thick
cream, and of a pure white colour.
Dh\ THOBP On Enet/8ted Tumours. <s;$
Case [II.— William Wallace, aged 6, was brought to me by his
father to have :i tumour extirpated, which, springing from the
cavity o\' the right orbit below the eye-brow, formed a prominence
in the upper [id aboul the size and shape of a small marble; die
Swelling, which existed from birth, was smooth and softisli. and the
skin over it presented no preternatural vascularity or deviation from
its natural condition. The cyst was exposed by a horizontal imi-
sion parallel with the folds of the lid; it, was very thin, and was
accidentally punctured, while separating it from the loose cellular
tissue around, so that the contents, which were limpid and clear as
water, escaped; however, the collapsed sac was seized with an
Asselini forceps and completely removed; it had a slight connexion
with the orbital plate of the os frontis.
Case IV. — On the 17th of last September, 1 removed an encysted
tumour from a girl named Mary Macklin, it was placed just above
the centre of the left eye-brow ; was oval in form ; about the size of
a kidney-bean ; presented an irregular surface ; felt rather firm ; did
not fluctuate ; was movable, and the skin covering it presented no
discolouration or alteration of structure. The sac was exposed in the
ordinary manner, and, after transfixion, completely dissected out ; it
was not adherent to the bone beneath. The contents were a mix-
ture of steatomatous substance, chalk-like material, and short slender
hairs.
No surgical subject possesses greater interest than the patho-
logical history of encysted tumours generally — the large size they are
capable of attaining — the deep position they occasionally occupy in
the visceral cavities, and their strange and unexpected contents
invest these formations with an interest not subordinate to that of
any others occurring in the organism. Although the mode of origin
of growths such as those produced in the ovaries, amongst the abdo-
minal and pelvic organs, at the bottom of the orbit, &c, cannot be
explained upon the principles long ago suggested by Sir A. Cooper,
the correctness of the views of this distinguished surgeon, as applied
to superficial and subtegumentary wens and cysts, can scarcely be
disputed ; various circumstances connected with the pathology and
symptoms of the tumours last referred to demonstrate their character
— they arc not new growths, but sebaceous follicles distended into
sacs, by reason of imperforate or obstructed excretory orifices, and
retained contents. Such swellings are commonly met with in situa-
tions where the sebaceous glands are largest and exist in greatest
G 2
1 hi. Thobp on
iiiitnl m : on tlie head, lure, and posterior I t the trunk;
w lun imall, they occupy a position immediately under tin- -kin, or
are oloserj oonnected with it; on the surface of the tumour, in
ly stage, and corresponding with the impervious opening of the
duct, a dark point may often be die 1 here a probe can I"-
pushed into the cavity of the follicle, and the contents expn jsed;
its interior is lined with a stratum of epithelium or thin cuticle, and
the contents, however heterogeneous, he they limpid afl water, viscid
as honey, pap-like or tatty, pultaeeous or etheromatoiis, hair- Of
horns, whether they present under the microscope the appearance of
epithelial scales, perfect or disintegrated, fatty particles, crystallized
or amorphous or other elements, they are all the secreted products
of the internal surface of the cyst, and correspond in every respect
with the substances which a tegumentary glandular follicle is capable
of furnishing. Facts like these establish beyond all doubt the
opinion of Sir .V. Cooper as to the follicular origin of encysted
tumours, when subcutaneous or superficial. But the fact of such
tumours being* occasionally congenital — adherent to bone — occu-
pying a position remote from the skin, and separated from it by a
layer of muscle, has opposed itself to the unexceptional adoption of
the doctrines enunciated in the Surgical Essays, and has led to the
opinion that certain swellings of this class, although not far removed
from the surface, are nevertheless adventitious growths — new for-
mations— differing essentially from the subcutaneous variety. But
it does not appear impossible that a body small at first, and connected
with the skin, or even developed in its substance, should as it enlarged
in size, come to occupy a deeper position, and be detached, in process
of time , altogether from its original connexions. Let us suppose
a cyst, for example, to originate in the skin, covering the orbicularis
palpebrarum, it enlarges in size and presses backwards, gradually
the fibres of the muscle separate, and the tumour passes through
them until the greater portion of its bulk lies upon a plane subjacent,
but, the tumour being globular, the action of the muscle must now
of necessity tend to place it in a still deeper position, and finally, by
reapproximation of its fibres, to close over and separate it altogether
from the cutaneous texture ; embedded at length in a loose areolar
tissue, in close proximity with the periosteum underneath (which is
fixed), and pressed upon in front by the muscular structure of the
orbicularis (which is movable), it necessarily contracts adhesion to
the former. It is no objection to this explanation to say, that
enevsted tumours are often congenital — the same causes are in
Dr. Thobp on Encysted 'rumours. 85
opeimtioB during uitra-uterine life u exist after birth — the Bkin is
formed at an early period of foetal development, and the sebiparous
glandules are in a slate of great perfection and activity at birth —
their orifices are probablj as Liable to become obstructed during
gestation as at any oilier period of existence, nay more so, from
anatomical imperfection if the anus may be oongenitally imper-
forate why should a follicle not suffer from an analogous abnormity.
In practice. enevMed tumours, provided tliat they have attained
a certain size, and ha\c existed for a moderately lone;- period, will
always he found underlying the subcutaneous muscles, when tin
latter present themselves; at Least my own experience does not
furnish an example to the contrary; and, when a bone lies near,
they are very prone to contract an adhesion to it, and indent its
Burfnce. No doubt the common wen, when it occupies the higher
regions of the head, seldom attaches itself to the pericranium, a fact
readily explained by the mobility of the scalp in which it is embedded,
and the intervention of the epicranial aponeurosis, the motions of
which it is compelled to follow, but within and about the orbit and
frontal region, where no such structure separates the tumour from
the fibrous covering of the bone, the two will be found more or less
intimately adherent.
Although the majority of encysted tumours of the orbital region
belong to the variety technically called hygroma — thin cysts with
watery contents — it is not to be supposed that this locality is not
obnoxious to other descriptions of these swrellings. The second
case detailed in this communication wras an example of etheroma,
and the sac possessed by no means an inconsiderable degree of
strength and thickness. In cases Nos. 3 and 4 the integuments
presented quite a natural appearance. In the third case the tumour
was not adherent. In one of the patients, the swelling was more
globular than oval ; and in the girl Macklin the cyst had an irregular
outline, and contained, not a fluid, but a suet-like substance,
calcareous matter and hairs. The conclusion, therefore, forced upon
me is, that encysted tumours in the neighbourhood of the orbit do
not possess peculiarities, although they frequently differ in many
respects from congenerous swellings of the head and face.
In all operations which interest surfaces so much exposed to view-
as the eyelids and parts adjacent, a point of no incon.-iderable
importance is the avoidance of unsightly sears and cicatrices, all
incisions here should, if possible, be parallel to the natural folds and
ridges of the skin. I have never found it necessary to deviate from
Dl Thobp <m Encysted Turnout
this principle, nor nave I ever met with ■ ease requiring ■ crucial
incision ; certainlj a vertical dii I — i « » 1 1 of the 11*1 should nol be practised
it' at all avoidable.
Although in removing the tumour Great caution i w r\ to
avoid an opening, it may be advantageous, on certain occasions, ai
the cyst has been for the greater pari isolated (as ivhen the bone is
deeply indented, or the tumour sinks far into tin- orbital cavity), to
permit a portion of the contents to escape through a small puncture,
the partial collapse of the sac will diminish its Bize, and thus permit
a more distinct view ot* its deep-seated attachments. In the nrst
case referred to it would have been perfectly impossible to effect the
separation of the tumour from the roof of the orbit, were not this
expedient adopted.
After the operation sutures are indispensable; the edges of the
wound, from want of due support, have :i great tendency to become
inverted; a few interrupted stitches made with a Blender sewing
needle and fine waxed thread, with strips of court plaster at intervals,
supported by a well-adjusted compress oiler the best means of
insuring an accurate union; as for metallic ligatures, 1 have almost
renounced them, and I am not ashamed to confess the hen -\
In cases where the total extirpation of the tumour is impossible,
from its deep position or intimate connexion with important organs,
a secondary growth is verj liable, in process of time, to make its
appearance. The tumour is said to " grow again;" but this language
is inaccurate: no doubt a swelling does grow, but it is an adventUioui
one, engrafted upon the remnant of the former cyst, which, continuing
to perform its function as a secreting surface, furnishes an unorga-
nized product that acts as a foreign body, round which the cellular
tissue solidities into a sac. It is thus relapses occur, and hence the
advantage of being able to remove every portion of the tumour.
When seated in the orbit, if deeply rooted, a cystic growth is one
ot' very serious import, and may easily be confounded with other
causes oi' Exophthalmos;* nor is laying open the sac, ami exciting
a suppurative action unattended with danger. We must recollect
that the periosteum of the orbit is continuous with the dura mater;
and further, that a delicate sheath of the subarachnoid cellular tissue
* Several years ago a case of exophthalmos was admitted into the City of Dublin
Hospital, under the care of Dr. Jacob. The eye-ball was greatly protruded, the cornea
dull, and the lids congested and of a purplish colour. It was decided to extirpate the
globe, and afterwards to remove the contents of the orbit, if necessary. The first
incision at the outer canthus opened a cyst, which immediately emptied itself, and
permitted the eye to resume its usual position.
I ) I r . Db RlCCl on Hie Watering /'laces of Switzerland. 87
is continued forward around the Mood vessels and aervea that enter
posteriorly; moreover, thai tin- ophthalmic La in communication
with the cerebral veins through the cavernous and other sinuses.
[nflammatioD may readily extend by any of these routes from the
orbital cavity to the brain and its membranes ; nor is this occurrence
by any means rare. Mackenzie, \Yardro|>, and other ophthalmic
Burgeons, give cases. When 1 read of encysted tumours frequently
operated upon, both in London and Dublin, before a radical cure
could he effected, I may lie permitted to congratulate myself at
being more fortunate with my cases.
Art. VIII. — Some of the Watering Places and other Health-resorts
of Switzerland. By H. R. De Ricci, M.D.
{Continued from vol. xxxii., p. 330.)
I was not strictly correct when I asserted just now that the water
of Loeche evolves no gaseous products; it does give off about 10
cubic centimetres of nitrogen, and two cubic centimetres of oxygen
and carbonic acid gas, in all about 12 cubic centimetres of gases
from every 1000 grammes of water, but no sulphuretted hydrogen
is evolved until the water has been bathed in, when its presence can
unmistakably be detected by the olfactory organs, without the aid
of lead test paper ; this is supposed to be due to the decomposing
action of the sebaceous exudations of the skin on the sulphates
contained in the water.
Although Loeche does not offer much in the way of amusements,
still its environs are full of beauty and interest. One of the curio-
sities of the place is the ascent called the ladders, which leads from
the valley to the village of Albinen, situated on a high alp on the top
of the Wrandnuch, on the right of the valley when looking towards
the Ghemmi. There is a constant intercourse going on between
the inhabitants of Loeche and those of Albinen, but, owing to the
precipitous cliffs which hem in the valley on all sides, there is no
path by which the natives can communicate except by going a
round of nearly six miles, whilst Albinen and the baths are not
more than one mile apart; one at the bottom of the valley, the other
perched on the top of about 150 feet of perpendicular rock. In
order to save themselves this long circuit, the inhabitants have for
Db 1 >i Ricci en tk Wa\ /' nd
i in the habit of scaling this perpendicular buttn
of ladders placed straight against tin- cliff, on
other, fixed to the rook in the moat primitive and unsatisfacfc
manner; the ladders themselves arc of tin* rudest construction,
about 1- feet Ions and three feet wide, the rungs being *ery far
apart, and joggling in their sockets; often rotten— always rickety —
the\ convey to ■ stranger who attempts to mount them the
most unmistakable feeling of insecurity; yet the inhabitants
fearlessly up and down at all tames and seasons- day and night —
men. women, and children, and accidents rarely happen. it is
surprising to Bee the heavy loads which these people carry up and
down those dizzy ladders, and fearful sometimes to watch two
parties meeting, one ascending, the other descending, when, in order
to pass each other, the least heavily laden lean- out over the pre-
cipice from the edge of the ladder to make room for the other to
pass
In this neighbourhood the larch grows wild, it is its native
habitat, and Borne of the noblest specimens of that tree are still to
he -ecu there: I measured one '2'2 feet in circumference, at ahout
five feet from the ground. About the middle of the latter halt' of
the last century, the Duke of Athole imported the larch into Scot*
land, and it was from the neighbourhood of Loeche (1 have b
told), that he brought the two original trees which have since
covered with their progeny half the mountain sides of Scotland.
Travelling was a very different matter in those days from what it
is in ours, and the Duke, who was travelling on horseback, is said
to have Carefully packed the two young sapling larches one in each
of his full jack boots. BO to keep them upright and preserve them
from injury. 1 believe that the original pair of larches which were
so brought over from Switzerland, arc still to be seen flourishing at
Blair Athole.
In what cases, in conclusion, should we recommend the waters of
Loeche to Our patient-? W we were to give heed to all that local
bath doctors tell us of the respective waters ot* their several spring
there is not an ailment which flesh is heir to, that would not be
cured by either drinking, plunging, or soaking in either one or all
of them. 1 have been at some trouble to make out, by the aid of
Dr. Mengis and Dr. Marc d'Espine, President of the Medical
Society of Geneva, a list of those diseases in which the waters of
Loeche are truly serviceable, and the following appeal* to be those
in which we may expect the most encouraging results : —
Dr, Di; Eticoi on the Watering Places of Switzerland, 89
First on the list we may place rheumatism, articular and mus-
eolar, and we may probably class with it mod forms of my algia and
neuralgia. Many forme of skin diseases, especially eczema, herpes,
impetigo, and ecthyma, which arc invariably cured ; unfortunately the
sameeannol be said iu cases of acne, psoriasis, and pytiriasis, although
they decidedly improve under the influence of the baths of Loeche.
In amenorrhoas and dysmenorrheaa, these waters may with safety
be recommended, as also in cases of vaginal discharges and bearing
down, caused by general relaxation of the uterine apparatus and its
appendages — we may add goitre, but I fear that unless taken at a
very early Stage, one would not be justified in expecting any great
results. The waters of Saxon, would, I think, be much more
powerful in dispersing those disfiguring tumours, were it not for the
unhealthiness of the locality where they arise, which, combined with
the mosquitoes and the suffocating heat, render them totally unavail-
able, at least to our British population.
Saxon is situated in the valley of the Rhone, on the left of the
traveller coming down from Loeche, towards the Lake of Geneva,
about halfway between Sion and Martigny. The mineral water which
supplies the bathing establishment gushes out more like a little
torrent than a spring, and it is an unfortunate circumstance that the
unhealthiness of the locality will always prevent us from making
use of it, for it belongs to that class of iodo-brominated springs
which are so powerful in the treatment of those diseases for which
they are indicated. I have not been able to obtain an accurate
analysis of these waters, but that they contain both iodine and
bromine is easily detected, even without an analysis, by the peculiar
saffron-like smell which they evolve on being exposed to the air for
a short time. Ossian Henry, in a paper laid before the Imperial
Academy of Medicine at Paris, states, that O110 grammes of
iodide of calcium and 0041 grammes of corresponding bromide are
contained in every 1,000 grammes of the water, thus greatly
exceeding in strength the somewhat similar waters of Kreuznach,
Wildegg, and Heilbrunn. I once met an interesting young patient,
a lady from the north of Italy, who was rushing away from the
baths of Saxon, unable to support the heat, the stuffiness, and the
mosquitoes of the valley of the Rhone. She had been ordered by
her medical attendant to those baths, solely from the account he
had read of their chemical composition, and probably without the
most remote idea of the topography of the place. She was suffering
from struma in a very aggravated form, labouring under caries of
i '' R 1 fuL
left el)
short .-•
iuijm.wui :n the DM of the water-. Mid fell rCTJ riisOOflSot
ul | e them op 1 endeavoured, bam
th the ice that the water ihe rained m much could
tra: 1 in bottle-, and employed in the seme ire»y, end for the
.e par] m ■ distance from the spring, end in any healthy
dity she might select; for the water i S • - -lI^
it i- is that cold mineral waters bear exportation better than
thoae which rise al a high temperature. Thii lady, at in;.
ted Champery, not far from the bathe of S where
tog to spend a short time, far her unmrner quart
and I thus had the opportunity of watching her. and studying the
of those water- at a distance from the Bpring, hut with the
adjuvants of bright clear bracing air. and no mosquitoes. This
lent improved wonderfully while under my care at Champery,
and though much of the general improvement was unquestionably
due to the invigorating effects of the pure air of the place, and the
a mild chalybeate spring, which rises near the village, and of
which 1 made her take some every day. yet the amendment of the
ulcers and the contraction and improved look of the Beyeral sup-
purating Burfi is undoubtedly due to the waters Saxon, with
which I kept them constantly wet by means of linen OOmpj - I
I think I can safely assert this, for whenever the Saxon water
happened t>» be run out, and that 1 dressed with plain spring wal
the granulation became flabby, the discharge unhealthy, and the
smell intolerable.
B tween Saxon and Villeneuve. and precisely at the point where
the Rhone has to force a narrow \ aeage for itself between the
mountains of the Dent du Midi and the Dent de Morcles, lie the
baths of Lavev. they are much frequented by the Swiss I bemsefa
and by French and Germans, but I do not think that they will
ever attraet many from these countries, as they labour under the
same disadvantages as the baths of Saxon, though in a minor degree.
The water o'i Lavev is sulphurous, but not to a very high degree;
it contains lime. Baa, soda, and strontian. and 100 cubie centi-
metres give of
Nitrogen. .... 2780
Carbonic acid. . 4*34
Sulph. hydrogen, . . . 351
It does not spring forth, but has to be pumped up from under the
Dr. De Ricci on the Watering /' laces of Switzerland. 91
bed of the Rhone, And thence conveyed in pipei to the baths, losing
in its course a considerable portion of its gateoilfl comj)oncnts and
much of its heat, so that, while at. the sourer itself it is pumped up
at a temperature of 43° centigrade, it has to be warmed over again
at the establishment, and by that means loses still more of its
constituent gases.
In the vicinity of Lavey are the salt mines of Bex, which are well
worth a visit. The principal gallery runs straight into the mountain
for about \\ mile, with an average height of eight feet and five feet
in width. At 400 feet from the entrance is a round chamber,
excavated in the solid rock, and used as a tank for dissolving the
rock salt. It is eighty feet in diameter and ten feet in height, the
immense vault of rock being totally unsupported in its entire extent.
The extraction of the pure table salt from the solutions of rock salt
is carried on exactly in the same way as at Kreuznach, in Germany,
and the mother-water, mutter-lailge, which remains after the salt is
crystallized, is employed at the baths of Lavey to strengthen the
mineral water, the same as at Kreuznach, by a certain quantity of
it being added to each bath, according to the requirements of the
case, and the directions of the resident physician. The most
important ingredients of the mother-water from the salt factories of
Bex are, bromide of sodium and bromide of magnesium, about 8
grammes of the former and 2^ of the latter to each kilogramme of
mother-water. The quantity of this mother-water added to each bath
of Lavey mineral water is about 2 litres at the commencement, and
gradually increases to 30 and 35 litres for each bath. This quantity is
seldom exceeded, nor long continued, and is gradually diminished until
reduced to the original 2 litres with which the patient had commenced.
The waters of Lavey enjoy a great reputation in Switzerland for
their efficacy in the treatment of scrofulous and rachitic diseases ;
they are also said to cure goitre and some cutaneous affections. I
have little doubt that they principally derive their curative powers
from the bromides of the mother- water, which is added to them,
though no doubt the combination of them with the sulphuretted
water will render it more efficacious in the treatment of those skin
diseases which it is said to cure.a
* It appears to me that we might take a practical hint, from the plan followed in
other places, of strengthening feeble mineral waters by the addition of the residual
waters of salt refiners, and employ some of the mxittcr-laiige of our own salt factories,
either diluted with plain water, or with water containing, like that of Lavey, a small
proportion of sulphurates, and apply it in the form of baths in the treatment of cutaneous
disorders and rheumatic affections.
Dl 1 b. Ri< i i om t) ring Plan rland
I mentioned above, that s young lady, luffering much from
rofula in in d form, had derived much benefit from bet
ourn at Champerj 1 think this placode more notice than
hai hitherto been beetowed on it, Dot a- a bathing place, hut as a
health-rdiort for the iummer months. I do not recommend it to
those who seek for pleasure in the excitement of the gaming table,
for, alas, there is no Casino, no Kur nasi, at Champery] l>ut for
those who can see beauty in the ever-varied works of the (it
Architect the pine-clad slopes, the towering rugged rocks, the
foaming torrent, or the still solemn wilderness of the glacier —
Cbampery will otter much enjoyment. It is situated nearly at the
top of the Yal d'lliers, a valley stretching up towards the mountains
of Savoy, from the left hank of the Rhone, ahout midway between
the baths of Levey and Villeneuve. Cbampery is ahout 4,500 f.
above the level of the sea, and beyond the region of mosquitoes; —
this invaluable quality can only he fully appreciated by those who
have felt what insects are; — to those who do not know them, 1
recommend one night at Martagny in the month of July or August
Cbampery is situated on the western slope of the valley facing the
fantastic profile of the Dent du Midi. It lias good accommodation
at a reasonable cost. It is admirably situated for mountain excur-
sions, from the easy ride to the Croix de Cnllot to the more arduous
ascent of the Dent itself, whose principal peak rises to about 11,000
feet. Another great advantage it possesses, i> in not being y« t
hackneyed; the people about the place are unsophisticated; and it
is refreshing to find oneself in Switzerland, at last out of the
universally beaten track, and for a time relieved from that human
flood which, by degrees, is converting that glorious country into an
overwhelming Cockney watering- place.
Not far from Champery, in the midst of a wilderness of pine
trees, is Morgins; it is reached by a track — I can scarcely call it u
path — which leaves the road from Monthey to Champery, on the
right of the traveller going up the valley. It possesses an hotel of
the most primitive kind ; but many Swiss resort to it yearly for the
purpose of inhaling the forest air, which, passing over the stems of
the fir trees, all encrusted and dripping with resinous exudations,
becomes charged Avith their odours and exhalations, and in the
curative powers of which, especially for bronchitic affections, the
Swiss place great reliance. I met there a most intelligent lady,
who during many years had Buffered from a chronic form of bron-
chitis, with excessive secretion ; she passed her winters at Montreux,
Dr. Db EtlCCl on the Watrrunj /'/(ices of Sic it? cr land, 98
on the Lake of Geneva, and the summer in the mountains, now in
our place and now in another; hut for the last three summer- she
had come to Morgins, in consequence of the great benefit .-he had
derived, as she expressed herself, from breathing the air charged
with turpentine. At the lime, this account did not make miieh
impression on me ; but having read, since nrj return, thai interesting
and excellent monograph of \h-. Corrigan's on Aroachon and its
pine forests, I wa> forcibly struck with the similarity*, and I now
place faith in the accounts which I received of the enrali\e effect!
of the air of Morgins. But not only those who Buffer from bron-
chitis and other pulmonary attentions, are said to derive benefit from
a summer residence among those pine forests; chronic ophthalmia
i- often caired, and always relieved; and also many other forms of
disease resulting from abnormal conditions of the mucous membrane.
The Swiss, not satisfied with inhaling the balsamic air of these
forests, and leading at the same time the most regular and healthful
life, endeavour to add still further to their manifold advantages by
taking what they call the whey cure; this consists in deluging their
insides with enormous quantities of the whey which remains after
the manufacture of goat cheese. This whey, of which they take
from 6 to 12 tumblers with the greatest gusto before breakfast,
Avas to me the most nauseous dose I ever encountered ; they drink
it tepid, allowing a quarter of an hour between each dose ! but one
taste was sufficient for me. As for any advantages to be derived
from it, excepting in so far as it acts daily as a purgative, I can see
none, and as whey is nothing more than milk minus its nutrient
properties, I am inclined to think that a bowl of the pure milk,
warm from the goat, with perhaps the addition of a lump of sugar,
and a table spoonful of rum or kirchwasser would, in all probability,
have been of far greater service to invalids. The great place for
the whey cure is Gais, in the Canton of Appenzell ; but wherever
the Swiss, French, or Germans resort for the summer, if there is
a goat to be had at all, its lucky possessor is sure to convert its
milk into whey.
Another favourite cure in Switzerland is the grape cure ; and of
this I beg to speak with far more respect. In the first place it is,
unlike the last-mentioned remedy, very pleasant to take, and in
the second instance it is of real service. Grapes will not cure con-
sumption as some have asserted ; but I have seen it do a wonderful
deal of good in cases of marasmus, brought on by habitual intem-
perance and indulgence in all sorts of excesses. I have seen persons
i i. EtlCCl ' ' ll •■' Ting Pla ■ \nd
who looked at iV consumptive, gain flesh and strength under the use
of large quantiti* and i friend of mine a highly intel-
ligent individual, who on leveral occasions had to take cod liver oil
in tliis country, not tor any pulmonary complaint, but for general
debilit) and wasting away — assured me that after eating for bcti
days from two to three pounds daily of grapes she felt invigorated
• 1 1 v ill the same wav as it' she had taken Ood liver oil lor the
as lapse of time. I would always recommend any patient that I
would send to Loeche, to adjourn to Vevey in the commencement
of September, after having undergone the ordeal of those hath-;
and at Vevey to finish the treatment by going through the proc
of the grape cure, than which no cure can be more simple. The
grapes are delicious, especially if you take care to purchase only
such as come from Aigle, and the cure consists in eating as many
of them as you can manage! the first thing in the morning — the
last thing at night — at breakfast, luncheon, and dinner; and I
never knew a patient to tire of them, nor resist their fattening
properties.
PART II.
REVIEWS AND BIBLIOGRAPHICAL NOTICES.
Observations in Clinical Surgery. By James Syme, Professor of
Clinical Surgery in the University of Edinburgh. 8vo, pp. 217.
Edinburgh: Edmonston and Douglas. 1861.
"It is my intention," says Professor Syrae, in his preface, "at no
distant date to publish some further illustrations of the principles I
am accustomed to teach." We earnestly hope to see this intention
carried out, as, in so doing, the distinguished Edinburgh Professor
will unquestionably give to the world, in the results of his
experience, a work not inferior to anything that he has already
done. Surgical cases, truthfully detailed, will never lose their
interest in the eyes of practical men ; and although the observations
of Mr. Syme, and the doctrines which he lays down with so much
authority, will not, nor ought not, to pass unquestioned ; yet, we
doubt not, that they will be considered with all the respect due to
an individual who has devoted his life, with so much earnestness
and success, to the cultivation and advancement of the science and
art of surgery.
The present volume of observations in clinical surgery consists of
thirty-five short essays on surgical topics, with illustrative cases.
It is obvious, therefore, from the very nature of the work, that it
would be impossible for us to give anything like a critical analysis
of it, and that the reader must, in the pages of the work itself, seek
out the views of the author on many of the subjects, from among
which we can but select a few.
Fracture of the Thigh Bone. — Mr. Syme starts by boldly an-
nouncing that there are few principles more entirely erroneous than
that extension is essential for the successful treatment of a fractured
thigh bone. This, indeed, he long believed, but is now convinced
that it is equally unsound in theory, and opposed to good practice.
nd Bibliographical A !
14 When it ii recollected," he "that tension is the pro]
itunulm to muscular contraction, the evils resulting from it will
not Appear bo surprising as that anv one Bhould so far forget hii
physiological principles as to ei in it. Instead of exciting the
muscles to contract, by subjecting them to extension, the gi
objects in treating a fracture should be to place them at rest, and,
\>\ protecting them from all sources of irritation, to oppose tl.
contractile action. To accomplish this, the prevention of motion ii
ofmosl consequence, and hence arises the great value of Mr. l'o
improvement in the construction of splints, (and, better still,
Deeault'fl splint acts on the same principle,) by preventing ani
the articulations from moving, and keeping the whole limb in a
tte of perfect quiet."
" In treating a fracture of the thigh bone, the first Btep should be to
draw out the limb to its proper length, direction, and shape; and, if this
cannot be done readily, on account of the patient's involuntary resistance]
it may be accomplished through the aid of chloroform. Two splints of
WOOd, leather, or pasteboard, the full length of the thigh, from the
trochanter major on one side, and the perineum on the other, to In-low
the knee on both sides, are then to be applied, and secured by four or
live looped bandages, and, lastly, the long splint, wrapped in a sheet or
table-cloth, of which enough IS left free for covering the limb, being
placed by the patient's side ; the loose portion is brought over, and fas-
tened to the board, after which, bv means of the perineal and ankle bands,
together with one round the body, the whole apparatus is rendered
secure."
Mr. Synie then gives the general result of this mode of treat-
ment, as seen upon sixteen cases of fractured thigh occurring in his
wards, from September, 1859, to March, 1861. The entire sixteen
wire treated without extension. In one of them there was short-
ening to the extent of one inch, owing to the complication of an
oblique fracture of the leg; in another, the limbs were found to be
of precisely the same length ; while, in the remainder, the shortening
varied from a half to three quarters of an inch.
Ununited Fractures. — A V it li reference to the treatment of un-
united fractures, Mr. Synie lays great stress on preventing, as
completely as possible, all motion of the part affected. He has
been long satisfied that the expedients in ordinary use, or, at least,
usually recommended, such as rubbing the broken ends together,
stirring up their connecting medium by the introduction of needles,
Stmb on Clinical Surgery. 97
or passing Batons through it ; if they were ever found to prove suc-
cessful at all, did so, not from their own direct agency, but from
the enforoemenl of rest conjoined with their employment, which
would hare been equally efficient, although not associated with
other remedial means. He contends that, under ordinary circum-
stances, the accomplishment of osseous union will take place, if the
parts are kept perfectly free* from motion by the proper application
of splints. To effect this, is, however, often by no means an easy
matter; it will he necessary to envelop the entire limb in a firm
case of starched pasteboard BO as to lock in immobility all its
articulations. If, however, the morbid condition is too firmly
established to admit of being remedied by this treatment, Mr.
Syme docs not hesitate to resort to what he pronounces emphati-
cally to be the only other means really capable of overcoming the
difficulty : this is cutting off the ends of the broken bones together
with the ligamentous substance connected with them, so as to
obtain two osseous surfaces, which may be placed in the proper
relation to each other, and steadily maintained in it by the rigid
pasteboard case.
" Case. — J. H., aged 34, a private of the — foot, while discharging
some duty in the Redan on the 8th of September, 1855, after the occu-
pation of Sebastopol, was blown up by a Russian mine which had escaped
detection, and, in addition to some slighter injuries, sustained a fracture
of the left arm, between two and three inches above the elbow. He
walked up to his regimental hospital, where splints were applied and
retained for a month, when, there being no signs of union, the ends of
the bone were rubbed together and supported by a starched bandage.
He left the Crimea on the 3rd of February, and was sent to the hospital
at Renkeioi, where a seton was passed through the seat of fracture, and
retained for five weeks without any benefit. On the 20th of May he
proceeded homewards, and after a long voyage of nearly two months
arrived at Portsmouth, whence he was transferred to Chatham on the 17th
of July. No attempt to restore rigidity was made there, and at the end
of two months he was dismissed the service with a pension of one shilling
per day in consideration of his disability, which was regarded as equal
to the loss of a limb.
" In the hope that relief might still be afforded, he applied to me on
the 22nd of January, 1857, nearly 14 months from the date of the injury,
and finding that the arm was entirely useless, through the extreme
mobility of the ends of the bone, which overlapped each other to the
extent of more than an inch, I resolved to adopt the only procedure that,
VOL. XXXIII., NO. 65, N. S. II
B biographical A '
id my opin khle prospect of remedy under such
circumstances, which tree, to remove the ends of the bone, and afterwards
atain the meei perfect reet, by placing th>- whole limh under
raint. Proceeding with this Hew, my first rtep was to bare the arm
put in an eat) position, with the elhow bent a1 a right angle, and then
covered from beyond the ehonlder to the tip of the fingeri with pati
board and itarched bandages, 90 as to form ■ ease, which, irhea it
une dry, effectuallj preTented the slightest movement in any of the
joints. This ease was nexl cat up on one Bide from end t<> end, -
allow the arm to be taken oat of it and undergo the requisite operation,
which was performed under chloroform. An incision having been made
along the outer edge of the triceps, I exposed the upper end ef the bone,
and sawed off a portion of it sufficient for obtaining a complete osseous
surface. The lower end, lying anterior to the shaft, could not be sub-
jected to the saw, but was removed to the extent of more than an inch
l.\ cutting pliers. The arm was then supported by a couple of Bplints,
an»l the patient lay quietly in bed for a fortnight, when the limh was
placed in its pasteboard ease, in which an aperture had been made over
the wound, then nearly healed, and discharging B \« rv little matter, that
soon ceased entirely. The patient feeling that the slightest motion \
impossible, even it" he had wished it, was relieved from any further
raint, and no longer remained in bed. At the end of a month, or,
altogether BIX weeks, from the date of the operation, which was performed
on the 30th of January, the limb was examined and found to be quite
straight, with a firm osseous union, so that the patient was able to Leave
the hospital, not only with his comfortable pension, but also with a
perfectly useful arm."
/nation of new Bone. — When speaking of this, we are glad
to find Mr. Syme admitting the important practical fact which
pathology and physiology have long since taught, although
practitioners have been slowr to recognise and admit it, that the
periosteum is the principal nidus tor the formation of new bone.
" New bone," he says, " may be formed to a certain extent by
orow'ino- out from the surface of the old one, so as to lessen the
size of an aperture, such as that made by triphining the skull, or
diminish the distance between the extremities where there has been
loss of substance in one of the long bones; but when produced
copiously, as in a case of necrosis, where there is complete restora-
tion, its formation certainly takes place in the periosteum, any
deficiency in which curtails its production to a corresponding
amount, and hence the irregular apertures observed in a new osseous
shell during the period of its formation, which, in the language of
Si mi; on Clinical Surgery. '.»!>
necrosis, are called cloacce, and were formerly attributed erroneously
to the effect of absorption induced by the presence of* confined
matter."
Amputation of the Ankle Joint Mr. Syme objects very strongly
to the so-called " improvements M made upon bis operation at the
ankle, and lie urges upon those who would desire to perform this
amputation with BUOCesS, the necessity of not taking directions as
to the true method of performing it at second hand.
"The surgeon of ;i large hospital told me that, having heard of ampu-
tation at the ankle, he had performed the operation repeatedly, according
to the direction of a London surgical manual, with the invariable result
of sloughing, hut that then, being advised by a friend to look into my
own book, he had altered the procedure with constant success
In performing the operation, the foot being held at a right angle to the
Leg, the point of a common straight bistoury should be introduced im-
mediately below the fibula, at the centre of its malleolar projection, and
then carried across the integuments of the sole in a straight line to the
same level on the opposite side. The operator having next placed the
fingers of his left hand upon the heel and inserted the point of his thumb
into the incision, pushes in the knife with its blade parallel to the bone,
and cuts close to the osseous surface, at the same time pressing the flap
back wards until the tuberosity is fairly turned, when, joining the two
extremities of the first incision by a transverse one across the instep, he
opens the joint, and, carrying his knife downwards, on each side of the
astragalus, divides the lateral ligaments so as to complete the disarticu-
lation. Lastly, the knife is drawn round the extremities of the tibia and
fibula, so as to expose them sufficiently for being grasped in the hand
and removed by the saw. After the vessels have been tied, and before
the edges of the wound are stitched together, an opening should be made
through the posterior part of the flap, where it is thinnest, to afford a
dependent drain for the matter, as there must always be too much blood
retained in the cavity to permit of union by the first intention."
Mr. Syme, eulogises his operation very highly on account " of its
facility and simplicity ;w we must confess, that we do not, by any
means, consider, that its chief merit lies in its facility of perfor-
mance; even upon the dead subject, and done in strict accordance
with Mr. Syme's directions, very frequent repetitions of it do not
justify us in regarding it as other than a tedious operation. It has,
however, other great and incontestable merits which, in our judg-
ment, render it more advantageous, in the majority of cases, than
any of the "improvements" upon it suggested by others. That,
ii 2
I: ' I- liograj
however, there are for which, the modification of Pn
Pirogoff, i Petersburgh, is well suited, we cannot doubl In
certain injuries of the foot, in attempting to retain part oi the
oalcis, one ie not running risk, af in casee of disease of tin- bonee, d
retaining a portion <>f the osseous tissue, justly Liable to the suspicion
of relapse. We are not, in fact, by tin- arguments of Mr. Syme
(vigorously put, no doubt), at all convinced, that the adoption of
thi- modification is to be regarded as a certain Bign of lax surgical
principle
/' f the Rectum and Anus. — It is indeed, very true, that
a surgical case i< read with interest by practitioners, not merely on
account of its individual features, but, because it illustrates the elect
ut' treatment, and enables them to determine the value of practical
principles far their own guidance. In no part of Mr. Seme's book,
le one more struek by the force of this, than in perusing hi- cases of
diseases affecting the rectum and anus: — Spasmodic stricture, and
fissure of the anus, fistula in ano, internal hemorrhoids, and pro-
lapsus ani, hemorrhage from the rectum, being each illustrated by
cases which are made the subject of sound practical comment.
Most writers have hardly noticed any other cause of hemorrhage
from the rectum, save that arising from the occurrence of internal
pile-; Mr. Syme, however, has met with, and details, BOme easts of
profuse and obstinate bleeding, where there was not the slightest
trace of internal hemorrhoids. That pendulous flaps of skin, Bays
Mr Syme, hanging round the anus, should give rise to a serious
flow of blood, seems, in the highest degree, improbable, and might.
indeed, be deemed altogether incredible, were it not proved beyond
the possibility of question, by well ascertained facts. As to how
the presence of external hemorrhoids causes bleeding from the
bowel, no attempt at explanation is offered; the facts, however,
because we do not see how to explain them, are not the less impor-
tant in practice, more especially, as Mr. Syme tells us, that he does
not regard such cases as being of, by any means, infrequent occur-
rence. Another source of hemorrhage from the rectum which he
speaks of, and which could not have been readily suspected or antici-
pated, is spasmodic stricture. The fissures and ulcers which are so
frequently connected with this condition, usually discharge a little
blood, although hardly in such a quantity as to constitute a promi-
nent feature of the case; but, independently of any such complica-
tion, a mere contracted state of the spliineter may occasion the most
profuse and serious bleeding; as an instance of this, Mr. Syme
Symi: on Clinical Surgery. U)\
mentions the ease of" a gentleman, n studenl of medicine, who com-
plained of bleeding at stool, hut who, <>n examination, was found so
perfectly free from hemorrhoidal disease, thai he was supposed to he
labouring under a delusion. Some time alto-wards he became
extremely pale ami emaciated, ami Mr. Syme Learned from a com-
panion, who resided in the Bame house with him, that there was
really a copious discharge ofblood, which issued in a fluid Btate and
then coagulated. On making another examination, it was found,
that the external part of the sphincter was tightly contracted; this
being judged to be the cause of the bleeding, a division was made
of the tight muscular fibres, This had the desired efFeet, no blood
was afterwards discharged.
"There is still another source of hemorrhage from the rectum, of
which, I have met with only one example. The patient wras a young
lady, whom I saw along with the late Dr. Graham, the Professor of
Botany. She had lost so much blood as to excite attention, by her
altered appearance, and was brought from the country in quest of relief.
I could not detect any hemorrhoidal disease, or any other recognised
derangement, but observed, that wThen expulsive efforts were made, the
blood issued from a small round orifice, apparently seated in a varicose
vein. To this point I applied a ligature, with the effect of affording
complete relief."
We have now given enough of extracts from Mr. Syme's work,
to place before our readers the form and general plan followed by
the author. As to its peculiar merits, and what appear to us, its
faults, we feel it would be presumptuous to speak in the language
of ordinary criticism. The long-acknowledged and justly great
reputation of the author, places him beyond the reach of this. That
a person in the position, and who has attained the eminence of the
Professor of Surgery, in the University of Edinburgh, should, as
he has done, and promises to do, set forth his views, and give to his
juniors the benefit of his vast experience, is, in itself, a proof not
only of his love of his profession, but of his earnest desire to estab-
lish what he believes to be true, and to spread the knowledge of
those principles which have made him a singularly useful and suc-
cessful practitioner. It yields unequivocal evidence of sincerity of
purpose and of a nature elevated above all sordid professional ends.
Holding this opinion of Mr. Syme, believing that, when he writes
(as he has not unfrequently done), with great acrimony, he does so
with the intention of attacking vigorously, what appears to him
nd Bibliographical A I
be false, we regrel that be doea not thou more readiness to
icknowledge in others the -aim- truth-seeking earm which
ia him; without, at the same time, by any means,
in- in man) of hi- dogmas. Enthusiasm and toleration rarelj go hand
in hand, Least of all, perhaps, in Scotland; hence, we must eXCUBC
the cuts occasionally made at hi- neighbours "on the southern side
of the Tweed;" hi- exposition of blunders or maipraxk, witnei
in the •• metropolitan hospitals of a neighbouring country;" while
we do not think that there is anything more than a little natural
self-glorification in the publication of Mr. Bransby Cooper- letter,
giving Sir B. Brodie's, Mr. Travers', and Mr Caesar Hawkins1
opinion of Lord *s case, in which Mr. Syme subsequently
obtained BO distinguished a triumph.
These characteristics, however, detract little from tin' real merit
of the book, for which the thanks of the profession lire, indeed, due
to the distinguished author.
l)es Hallucinations, on Ilistoire RaisonnSe des Apparitions, des
Visions, des $on<jes, de VExtase, des Rives de MagnStisme et
de Somnambulisms. Par A. Bbiebbe de Boismont, M.D.
Troisieme edition. Paris: Bailliere. l;St>2. 8vo, pp. 718.
Chi Hallucinations , or A Rational History of Apparitions^ Visions,
Dreams, Extasyy the Dreams of Magnetism and of Somnambulism.
By A. Bbiebbe i>e Boismont, M.D.
TriE work of M. Brierre de Boismont, a third edition of which lies
before us, has long enjoyed a high reputation, partly due to the
exceeding great interest naturally belonging to the subject, and
perhaps as much to the admirable manner in which the distin-
guished author has achieved the task, for which his learning and
industry so well qualified him. The former editions were not
noticed in our pages ; and we therefore regret that space will not
admit of our going as much into detail as would be desirable, to
give our readers an adequate idea of the excellence of this impor-
tant contribution to psychological medicine. Our efforts shall be
directed more to cull from its pages, than to enter upon the task of
elaborate criticism, and to thus excite curiosity and induce a
desire to peruse the whole. Before commencing the history of
Di: Boismont on Hallucinations. 103
hallucination8| our author observes thai false perceptions were
noticed by the ancients, and thai they even distinguished halluci-
nations of sight, of hearing, and of odour. The definition of hallu-
cinations is referable to remote antiquity, bul to Arnold may l>c
attributed the credil of having proposed one which is almosl com-
plete. Attn- quoting the definitions of Arnold, Crichton, Esquirol,
Calmeil, and others, lie gives his own, which we may best transcribe
in the original words, " rhallucination, la perception des eignes
sensibles de L'idee; el fillusion, ['appreciation fausse des sensations
reelles."
The word hallucination, in scientific language, is applied, in
general, to thai mental condition in which the individual (to use
the words of Arnold), imagines he sees, hears, or otherwise per-
ceives, or converses with persons or things, which have no external
existence to his senses at that time. The second chapter is devoted
to the consideration of hallucinations compatible with the posses-
sion of reason ; and, it abounds with the most remarkable instances
on record, derived from various sources. We may extract a few of
the most interesting. Some of these hallucinations are of the most
pleasurable character: — Take, for example, the case of a " Savant,"
who had lost, soon after marriage, a wife, ardently beloved, but
who, many years after the tomb had closed upon her, was present to
his sight in all the majesty of her beauty, when, on returning to
his country house, he placed himself in the vicinity of a spot she
was in the habit of frequenting. How different would have been
the sad reality, when age had bereft the once fair form of every
charm which, in by-gone days, had so captivated him —
" And the loved forms, he never more must meet,
Are with him in the vision, fair as when,
Long years ago, they clasped his hands at parting."
The letters on Natural Magic, by Sir David Brewster, and the
History of Demonology and Witchcraft, by Sir Walter Scott, afford
examples of the most wonderful hallucinations. In the case of
Nicolay, communicated to the Eoyal Society of Berlin, wre have
the subject of the hallucinations himself, studying and analysing
his sensations, and assigning the appearances of the spectres to a
lesion of the cerebral circulation.
The effect produced by apparitions, varies in different cases.
Nicolay became familiar, as it were, with them, and they caused
him little disquietude; whereas the distinguished person, whose
hi I md Bibliographical A I
history wna communicated t<> Sir Walter Bcotl bj an eminent
physician, died a prey to tin- agon) which harmed the last
of bifl life
\ state of weakness, oonvaleaoence, and the prodromal symptoms
of asphyxia, are occasionally productive of hallucinations. Leuret,
himself a physician, relates a strange hallucination in his <>wn
person:— He \\ :is attacked by influenza, and he was bled; after
which he became weak, but without Losing consciousness, and he
remained so for eight hours. He distinctly heard a flask placed "i»
the table beside him, and, immediately after, a crepitation a- if an
acid was poured on a carbonate; he supposed, at first, that an acid
had been spilled on the marble table. Haying satisfied himself that
he neither dreamed nor was delirious, he came to the conclusion
that he had been deceived by an hallucination.
Andral was the sport of a strange illusion, when, labouring under
indisposition, he perceived a dead body for some moments in his
chamber.
Our lamented friend, Sir Henry Marsh, related to us, many yean
since, an interesting example of an illusion of which he was himself
the subject. Early in his professional life, he devoted himself with
much zeal to the investigation of the phenomena of fever, the results
of which he published in the 4th vol. of the Dublin Ilospitnl
Reports, under the title of " Observations on the Origin and Latent
Period of Fever," a memoir which proved that he possessed in a
high degree those qualifications which enabled him to attain the
foremost rank in the profession of medicine. While engaged in
close attendance on the sick, Sir Henry Marsh contracted the fever
which then prevailed as an epidemic. He was attended by Dr.
Cheyne, and, for a considerable period, while labouring under the
disease, whenever Dr. Cheyne entered the room, he saw a second
figure, resembling in the most minute particular his friend, Dr.
Cheyne. The two figures — one, the real man; the other, as it
were, an impersonation of him — were before him. He was all the
time perfectly aware that the second figure was a phantom of his
brain, which had no existence but in his disordered imagination.
In Abercrombie's Inquiries Concerning the Intellectual Powers,
there is mention made of a man who had been all his life a prey to
hallucinations. When he met a friend in the street, he did not
know, at first, whether it was the veritable person, or a phantom ;
but he was soon able to distinguish, by the sense of touch, or by
listening for the noise of the footsteps. This person had, moreover,
Db Boismont on Hallucinations. 105
the power of recalling the creations of his imaginatioD by an effort
Of will.
M. Brierre de Boismont, under the head of hallucinations com-
patible with the possession of reason, refers to many talcs, wliich,
we fear, are either altogether apocryphal, or belong to the category
of hallucinations of the insane. The visions of Constantine, of St.
Genevieve, and of another maiden, who, coming ten centuries later,
was a second saviour of France, are alluded to.
Passing from ancient to comparatively modern times, we have
the hallucinations of Oliver Cromwell, of Descartes, Malbranche,
Pope, Byron, Goethe, Bernadotte King of Sweden, &c, &c.
M. Brierre de Boismont next proceeds to consider hallucinations
in connexion with illusions, and rightly observes, that the study of
the former should not be separated from the latter. He then gives
the differential character first established by Esquirol: in the case
of hallucination, the absence of any external form ; while, for the
basis of illusion, there must be some sensible object. A man affirms
that your figure is that of a cat, or of Napoleon ; he is the subject
of illusion Another, who, in the night time, hears voices which
speak to him, and perceives personages which no one else can
discover, is under the influence of hallucination. The privation of
sight and of hearing is no preventative to hallucinations, whereas
it is an obstacle to illusions.
M. Dechambre, however, thinks Esquirol is not justified in
making the distinction. The person who, under the dominion of
an hallucination, believes that he hears voices, which speak, and the
person who, under the influence of illusion, having a friend before
his eyes, believes that he sees an ox or a devil with horns, present
no fundamental difference ; for in one, as in the other, it is the brain
which is diseased, and not the organs of sight or of hearing. That
illusions frequently exist with hallucinations, and that they mutually
pass one into the other is matter of every-day experience.
M. Brierre de Boismont persists, notwithstanding the opinion of
Calmeil, Aubanel, and others, in considering the two orders of
phenomena as distinct, chiefly from the fact before referred to, viz.,
the necessity for the presence of an object in illusions, and its
absence in hallucinations.
It is familiar to most people that illusions are compatible with
perfect sanity, but that such are easily corrected by the power of
reasoning. Should such false impressions be called illusions ?
Dr. Forbes Winslow observes : " As long as the judgment
1 1 > i ; l: B liographical A !
liu- tit.- power of correcting the false impression! made through
the sensuous organi upon the brain, the noticei thus conveyed to
the mind cannot, In scientific phra died either illusioi
delusions, or hallucinations; but the) become so when th<
at and unreasonable in their character, and the judgment
ceases to operate in re< tit\ ing t lu- false ideas, and tin- conduct of the
individual is evidently influenced by them."
Some false impressions are easily corrected, and are well known
to all: Buch as, for example, a square tower appearing to be round,
when viewed at a distance, &c., &c.
There arc others, however, the veritable cause of which has only
a appreciated in later times, owing to the progress of science:
luch as the optical phenomenon of the Hart/. Mountain-; the Giant
of Brooken ; and the phenomena of like character observed in
Westmoreland and other mountainous countries.
Many circumstances give rise to illusions, of which ignorance is,
doubtless, the chief. The traditions met with in different countries
arc in a great measure, due to illusions of sight.
The following anecdote, told by Dendy, proves that an event
which has made a powerful impression, aided by an association of
ideas, may produce an illusion: — " Some days after the execution of
the Prince of Moscowa, an evening party was assembled at a house
in Paris. The servant, whose duty it was to name the guests as
they arrived, hearing the name of the M. Mareehal ainc, announced
M. le Mareehal Ney. An electric shock pervaded the whole
Company ; and the narrator declares, that the resemblance to the
Prince was, in his eye, for a BOCOnd, afi perfect as if it were reality
Many oi' the tales recounted in ancient times may be explained
on the supposition that illusion of sight or hearing was the prox-
imate cause. Our author refers to the story of Ajax attacking the
-wine, of king Theoderic, of Bessus, &C., &c. Illusions of sight
and hearing have sometimes assumed an epidemic form. The tate
of battles have been decided by illusions according to ancient his-
tory. During the battle of Platea the air resounded with terrible
cries, which the Athenians attributed to the god Pan, and thence,
according to some, the word panic.
Touching the frequency of hallucinations among the insane,
according to Esquirol 80 per cent, are subject to hallucinations :
this our author looks upon, with reason, as too high a calculation.
It is among monomaniacs that they are most frequent. Marc
observed a man who, from reverse of fortune, had become melan-
De Boismont on Hallucinations. 107
obolic ; for many yeara he had not spoken a word, his sole occupation
consisted in smelling and licking the walls. On one occasion the
superintendent, without appearing to remark him, asked what had
caused the dirty marks and depressions on the wall. The silence
which had existed for years wras broken, and he exclained "Do
you call those dirty marks do you OOl see they are oranges of
Japan ?" What delicious Bruits, what colour, what odour, what
an admirable taste! and with redoubled ardour he applied himself
to his task ; henceforth, instead of looking upon him as one of
the most unhappy inmates of the asylum, it was evident that his
delightful hallucinations of sight, of hearing, and of smell, were
the means of procuring for him endless enjoyment.
Hallucinations of hearing are the most frequent by many de-
grees, and the privation of the sense is no obstacle, as persons who
were deaf have held long dialogues with imaginary beings. The
invisible speakers may be internal or external. The voices may
come from the heavens, from a neighbouring house, from the
corners of the room, &c, &c. ; they may emanate from the head,
from the belly, or some other part. Hallucinations of hearing may
be simple, or combined with those of sight and the other senses.
In all times, and among all people, hallucinations of sight have
played an important role ; to them are particularly attached the
name of " Vision," and to the affected, " Visionaries." In ancient
times, and in the middle ages, the belief in visions was general.
Hallucinations of hearing, and of sight, are often united ; as in
a remarkable case of a man who held frequent communications
writh denizens of the other world, conversing with Moses, dining
with Semiramis and being on intimate terms with Richard the
Third. On being asked if he had questioned Richard on the
subject of the murders he had committed, and what answers he
had given, he said — " What you call murder or carnage is, in
reality, nothing. Cutting the throats of some 15 or 20,000 men
does no harm, they pas3 to a better world and a more perfect state
of existence. The man who reproaches the assassin is guilty of
ingratitude."
Hallucinations of touch are surrounded with difficulties as regards
their study ; they are confounded with neuralgias and visceral
illusions.
We remember seeing a gentleman some time since who supposed
that he was the victim of persons who were perpetually sending
electric currents through different parts of his body. He passed
I: ■ • and Bibliographical Notia
irhok dayi in i boat, m h<- assured qi from the experience of the
thai while on the sea his enemiei had no power over him.
Calmei reporti the case of ■ veteran wrho believed thai each oighl
he ivai nailed in a coffin and transported from Charenton to Vin-
eennes, irhere :i maai for the dead ivas ohannted in the chapel of
the palace ; by the same invisible personages he waf broughl l>;i<-k
and placed in his bed. The sensation of flying is very commonly
experienced. M Brierre de Boismont frequently found a literary
friend of his with eyes fixed, who exclaimed — "Je vole, ne iiiarritez
pas!' When he was restored to himself, he recounted his sen-
sations. This has been reported in ancient times.
St. Jerome says, that he experienced in dreams the sensation of
flying above the earth, over mountains and seas. Madame d'Arnim,
the friend of G be the, believed that she flew and hovered in the air.
The sensation of hovering was to her a delicious feeling.
Hallucinations of s)ncll, like those of taste, are rarely isolated ;
thev are generally associated with those of hearing, of sight, and
of touch. Some of the insane experience the most pleasurable
sensations, and again there are others who suffer pain from the
presence of these hallucinations.
The saints frequently get the credit of diffusing odours with
which the perfumes of Araby can scarcely be compared, and devils
are believed to spread around the most abominable and disgusting
stinks.
Hallucinations of taste, are of the most pleasurable or distressing
character. Some are engaged in smelling imaginary viands and
liquors, in swallowing ambrosia and nectar ; others in eating raw
flesh, arscnie, &C, &C. We remember a patient who, after eating
a good dinner, became suddenly sick, exclaiming that he had been
eatins human flesh. With reference to the existence of hallueina-
tions and illusions in mania, our author has collected 229 obser-
vations. Of this number 178 exhibited these phenomena, and 54
manifested no false perception. There are numerous instances of
mania suddenly arising under the influence of an hallucination.
A woman saw a friend in a dream, who, at the time, was in Africa;
he told her he had perished in combat, and he presented his hand
to her, she touched it and found it cold ; she awoke with a bound,
and she was found to be in a state of mania. Under the domination
of an illusion suddenly taking possession of a person, crimes have
been committed, and to the psychologist the proof is conclusive, that
the individual has lost the power of will, and that, therefore, he is
I)i: Boismont on Hallucinations. L09
not accountable, but unfortunately the law does not recognize
impulsiye insanity. Some maniac- slay, because they think the
devil is before them; others, because they ohey some command-
ment. His satanic inajoty plays an important part in many cases.
A woman once informed her husband that. Satan lay with her
every night. ( )l" 303 patients labouring under melancholia (mono-
manic triste of our author), 248 were the prey of hallucinations
and illusions, and of these 21 '1 presented all the characters of pain.
In general, the apparitions have a hideous and frightful form;
sorcerers and devils coming out of hell arc frequent, particularly
■with females.
In some examples of this form of mental aberration, the halluci-
nations and illusions owe their origin to a real event. The night
before a judge wras obliged to pronounce judgment in a case, in
which one of his friends was the accused ; the culprit's wife pre-
sented herself to him, and urged upon him every appeal which
could move the heart. On finding him inexorable, she fainted, and
was carried away dying. The judge did not fail in the performance
of his duty ; but, the event made such an impression on him, after
a little time, as to occupy his thoughts altogether ; he believed that
he had exceeded his duty, that every one addressed reproaches to
him ; his life became insupportable, and after an attempt at suicide,
he wras brought to an asylum.
Although, in general, the hallucinations and illusions in melan-
cholia, are remarkable for fixity and durability, they, nevertheless,
in some instances, suddenly, and when least expected, disappear.
A man who had abstained for a considerable time from food,
because a voice had commanded him not to eat, suddenly returned
to his ordinary habits, the voice having ordered him to eat. The
reluctance to take food arises, in some cases, from hallucinations on
the subject of money.
M. Brierre de Boismont, records 28 cases of puerperal mania, 18
of which presented hallucinations and illusions, and 3 manifested a
suicidal propensity.
Dementia is frequently associated with hallucinations and illusions,
which may last for years ; they may then be, as in other forms of
mental alienation, continued, remittent, or periodic.
In that form of dementia, accompanied by general paralysis,
hallucinations are present in many cases, but only in its early
stages.
The seventh chapter is devoted to the hallucinations of Intoxication,
lli) // /. liographical A !
using the word in the generic mum-, at comprising alcoholic drinl
opiuna, haschisch, & and be observes, thai the
hallucinations, \i/, visions of animals, reptiles, which
observed in delirium tremens, are noA peculiar to it, but are met
with equally, in the delirium produced by belladonna, datura §tra-
monium, nyoscyamus, &c. En the observations on the effect! of
opium, our author draws largely from the confessions of an English
opium cater.
In the eighth chapter, the hallucinatione of catalepsy, epilepsy,
hysteria, and hypochondriasis, are described. The following oon-
clusions are arrived at : —
Hallucinations arc rare iu catalepsy, owing to the suspension of
the intellectual faculties. The complication of epilepsy with insanity
explains their greater frequency in epilepsy than in catalepc
Hysteria IS often marked by hallucinations, which may be compati-
ble with sanity, or may be associated with mania, monomania, or
dementia.
The fixity of the ideas in hypochondriasis, is favourable to the
production of hallucinations. In chorea, hallucination- are observed,
but principally in the acute Btage. They have been frequent in
epidemic chorea.
They have also manifested themselves in hydrophobia, in lead
colic, and in many neural affections.
The hallucinations of febrile diseases are next brought under our
notice. They may, in point of fact, complicate all disease-, or they
may he, in some cases, their precursors.
The principal diseases in which hallucinations have been observed
are inflammatory fevers, congestions, inflammations, diseases of the
brain and its membranes, inflammations of the lungs, lesions of the
digestive organs, typhoid fevers, the plague, intermittent fever-,
gout, certain diseases of the heart, (fee., <&c.
We would gladly quote at length from the chapters which
follow, in which subjects of surpassing interest are treated with
great ability, but we are reminded of the length to which we have
already gone. Passing over the chapters on hallucinations in con-
nexion with history and religion, which are replete with information
conveyed in the most attractive form, we shall devote a brief space
to the subject of the treatment of hallucinations. The first question
which is to be considered is that of isolation, or treatment at home.
In some cases, separation from family and friends becomes a
necessity ; and in others, it is not expedient. The treatment is
De Boismoni on Hallucinations. Ill
divisable into physical and moral means; and, t<> illustrate die
Bubject, our author refers to cas<
The therapeutic agents which have been Pound most useful are
blood-letting, baths, purgatives, and blisters, to which may be
added, occupation and exercise.
In hallucinations with excitement, be has found general baths of
six, eight, and c\cn ten hours1 duration, with irrigation, of great
advantage.
With respeel to blood-letting, lie mentions one case in which
it was productive of syncope, followed by blindness, but not by cure
of the hallucinations. The unlucky patient was a physician.
In delirium tremens, with cerebral congestion, thirty leeches,
applied along the sagittal suture, were beneficial. A powerful
shock, physical or moral, has frequently been productive of the cure
of hallucinations.
Medicinal agents effect a cure sometimes; not by their thera-
peutic power, but by breaking the chain of ideas ; as, for example :
opium, by producing sleep long protracted beyond the accustomed
time. We can only briefly refer to some of the cases. A man
believed he was exposed to magnetic influence, and that the mag-
netizer resided in his belly. With a view to divert his ideas, and
to relieve the ailment of his stomach, of which he complained, two
large blisters were applied to his legs. His countenance, which had
been sad, soon assumed an appearance of gaiety, and, by the aid of
the distraction produced by intellectual labours, the cure was com-
pleted.
A young lady, who was crossed in love, saw her lover every-
where— in the sky, at one time, and he spoke to her, and she
responded. After a week she completely recovered, under the
influence of a daily bath of four, five, and six hours' duration,
irrigation of the head being employed at the same time.
The cure of hallucinations has been due to violent measures,
which, in truth, humanity cannot approve. The douche, in the
hands of Leuret, has been successful in compelling the insane to
give up their hallucinations, admitting their absurdity. With
others, the treatment has not had the same result.
The continued irrigation is far preferable to the douche. It may
be practised by a streamlet or a number of streamlets falling for
hours on the head, from a watering-pot ; after some hours of this
treatment, patients have begged to be taken out of the bath,
admitting that they had been deranged, but that nowT they were
\[2 U \nd Bibliographical A
our l \ >ung lady, ut'tcr tw«> hours of the irrigation, exclaii
\1 Bri rre de Boismont : ** Monsieur, faites moi sortir d'ici
eau qui me tombe oomme, une pluie Bur la tete, m'esf insupportable.
\ oue I'avei fail paroe quej'etaig folle, je Le 9ais; mais, Dieu merci,
j'ai toute ma raison." Before complying with her request, b<
her what had become of the figure which hud pursued her ev<
where She answered that it no longer existed; it was an illusion
caused by her fever. In eight days she was restored to her family,
perfectly well. Hallucinations of recent origin have been known to
cra.se on the day, or the day following, admission into an asylum,
such has been the effect of the mental impression.
Many parts of M. Brierre de Boismont'a work have not been
touched on; but we trust we have attained OUT object, namely, to
excite an interest in the subject among our readers who may not
have devoted much attention to the study of the phenomena
resulting from the " mind diseased."
Return to an Order of the Honourable the House of Commons,
dated bth August, 18U1, for Copy of the Papers relating to
Quarantine. Communicated to the Board of Trade, on the oOth
of July, 1861. Blue Book.
In the 62nd number of this Journal, .May, 1861, we gave a
lengthened notice of two papers relating to quarantine and quaran-
tine laws, copies of which had been returned to orders of the House
of Commons, in May and August of the preceding year, and we
then felt it our duty to speak in earnest terms of the arduous and
most valuable labour which the " Quarantine Committee of the
National Association for the Promotion of Social Science" had
performed, in the compilation and digest of the evidence upon
which those returns are based; and now we have the satisfaction of
bringing before our readers a report founded on the evidence con-
tained in the two parliamentary papers referred to. The present
11 Return" contains, first, some additional evidence and information
respecting quarantine which had been communicated to the Board
of Trade ; and next, a complete digest of the numerous replies that
were received by the committee in answer to the queries which had
been issued at the outset of their labours, and which were trans-
mitted to Her Majesty's Consuls, the Governors of Colonies, and
Quarantine. L18
the principal Medical Officers of the Navy and Army on foreign
stations. Bach of these queries is reproduced and illustrated, in
the order in which they Btand, l>\ copious details and practical
remarks, and the general conclusions to which the committee came
arc Btated, anil which they "considered to be clearly dedncible from
the evidence submitted to them;*1 the Report then winds up with
"a lew Bimple recommendations on certain points of practice naosi
easy of adoption, and whose general adoption would, in our." the
committee's "opinion, insure immediate advantage.'1 ( tfthe elaborate
Report before us, we confess it would be very difficult to give any-
thing like the Length of critical analysis to which it is entitled, and
We must, therefore, content ourselves by taking up some of the
most important of the conclusions at which it has arrived, and
glancing, hastily even, over them. Lest, however, these remarks
might lead the " committee on quarantine" to imagine we under-
value their labours, we beg to premise the remarks we intend to
offer with this assurance, that we hold to the statement we made
when reviewing the two first parliamentary papers on quarantine,
viz. : — " In fulfilling this arduous task, the quarantine committee
have performed a most valuable labour, having alike done good
service to the interests of commerce and to the cause of sanitary
science." Nay more, we may say, that if this statement were
applicable to the former undertaking of the committee, as it surely
was, it is even more so to the present, which is a full and practical
summing up of the evidence which had previously been collected,
and which has been so ably analyzed and digested.
The first inquiries that naturally suggest themselves to any one
taking up the subject of quarantine are — what is it? why has it
been imposed? and what have been its results? Now to these
queries we consider the inquirer will find conclusive answers in the
Report of the Committee on Quarantine; and we believe that any
one who will attentively, and without prejudice, study this Report,
will learn that quarantine is a fallacy, based upon very unsound
and most unscientific assumptions ! That it has been, and is, imposed
upon false principles, equally at variance with equity, humanity,
and common sense; and that, as might be naturally expected, it has
failed in affording that protection from epidemic and contagious or
supposed infectious diseases, which it was ostensibly designed and
hoped to give: hence its results, as regards protection from disease,
are \ erv uncertain, or have been proved to be nearly negative,
while the injury to trade and commerce has been positive and
vol. x win., NO. G5, n i
lit
undoubted t ta tin ral point* we shall quote some illustrativa
observations from tin- Report bei and first,
quarantine reallj ia
l.uiv persona imagine that quarantin • simple affair, and
that ;ill which i> meant or occasioned by it Lb i I i * - detention, for a limi
thm-, and the purification of infected or suspected vessels, with their
crews and i ■ , iii consequence of the actual or recent existence of a
dangerous contagious disease, either on board the vessel, or in the port
horn whence Bhe sailed. But this is far from the reality. In a is
proportion of the cases where quarantine is Mill imposed in many coun-
tries, n«»t only no sickness of any sort has existed in the vessel during
the whole voyage, but OO instance of the disease, on account of which
she is subjected to quarantine on arrival, was known to have existed for
a length of time in her port of departure." . . . u In the majority,
however, of eases in which quarantine ia impo sdty
rests upon, not a merely gratuitous apprehension, but upon the ascer-
tained, or the rumoured existence of a dangerous transmissable disease in
the port or country from which the vessel has last come."
"All on board, indeed, may have been healthy during the voyage, and
may be so on arrival, btit the fact of the vessel having come from an
infected or suspected locality, is held sufficient to require that she, and
every person and thing on board, should undergo a specified detention,
for the protection of the public health. The quarantine is directed against
the Hen de provenance, or port of departure; and this is the reason why it
involves all arrivals therefrom without exception, whether sick or well;
although when sickness has also occurred on board, the quarantine is
usually more stringent than when the vessel has remained quite healthy
during the voya
The Report abounds in instances illustrative of the preceding
statement, and moreover, shows over ami over again, that ill several
countries, Spain and Portugal especially, the imposition of quarantine
does not depend upon any supposed or alleged existence of disease IB
the nations from which the arrivals have come, much less upon any
Sickness on hoard; hut is evidently enforced from political, and
particularly, fiscal motives. In Spain, Portugal, and some of the
Italian States the most arbitrary and unequal laws exist relative to
quarantine, and these laws are usually stringently enforced; but
in France and Sardinia, on the contrary, whose existing quarantine
codes are based upon the recommendation of the international con-
ference held at Paris, the quarantines have, for several years, been
mild in all cases; indeed the imposition of them at all seems to
Quarantii I 1 -r»
depend more upon what neighbouring states demand, rather than
on any belief in the protective agency tli:it quarantine affords to
the ] >i 1 1 >1 it * health; and this statement also holds good regarding the
British possessions in the Mediterranean, l>ut if we did not impose
in Gibraltar, for instance) nearly similar restrictions to those en-
forced by Spain, the consequence would !><• thai thai country would
close all communications with as! And. as Btated in the Report —
11 Were Spain to modify her sanitary restrictions, it would confer a
greal benefit on ( iibraltar."
The Report gives many examples of the want of equity with
which quarantine is enforced in several places. Thus, while at Vigo
the English packets from Southampton, with clean bills of health,
were subjected to quarantine upon some frivolous pretence; "at
Malaga, on two very recent occasion, certain authorities and persons
of rank arriving from places infected with cholera were admitted
immediately. A royal ordinance has been also issued, commanding
that troops and military stores coming from infected places, should
not be subject to quarantine. " Surely such examples as these, and
there are several such in the Report, fully confirm the statement
we have made — that quarantine is usually imposed or enforced upon
false principles, at variance with equity and common sense.
With regard to the results of its imposition, we might refer
largely to the several parliamentary papers upon the subject, to
show that quarantine has proved quite abortive in affording pro-
tection from the plague, yellow fever, or cholera, the diseases
against which the most stringent portions of its absurd, often
iniquitous, code have been levelled. But we need not do more than
quote the following statement from the Report : —
" Many of the consular replies contain strongly expressed opinions of
the inconvenience and injury inflicted by the operation of the quarantine
regulations in force, while no real security is afforded to the public
health of the port or country. There appears to be a general distrust
and disbelief in the utility of the system, as at present pursued."
Such, we are satisfied, must be the conclusion at which every
intelligent and unbiassed observer must arrive; for nothing can be
more certain than this, that every one who has seen or has studied
the modus operandi of systems of quarantine, must have become
impressed with a thorough distrust in their operations, and has been
led to feel that the sooner such a gigantic fallacy is nearly, or com-
pletely, done away with the better; certainly for our own part we
r -2
1 hi // nd Bibliographical .\ !
nui thai after considerable experii nee of quarantine in leveral
eountrieB, and after witnessing the total failure of it to accompliah
the objects for which it was ostensibly designed the protection of
the public health, and the prevention of epidemic di ire
haw no hesitation in urging— either its entire abolition, or :it
I such a modification of its absurd code, diversified in each
country according to the amount of ignorance thai prevails — thai
the positive evils which it at presents generates shall not l>e allow- 1
t<> continue! Every one, we would imagine, musi agree with the
conclusion of the committee on quarantine when they say that —
•• All unnecessary interruptions to international intercourse cause
not only urcat personal inconvenience, hut Berious commercial Los
a conclusion at which they have arrived from the ample evidence
ire them, which showed them that —
" Great diversity and discrepancy exist in the system of quarantine pursued
in different countries," that — " Much of the practice still in force is cer-
tainly uncalled for, as regards the public health, and seems to he retained
on fiscal, rather than on sanitary grounds:" again, that — "quarantine
restrictions appear to have been sometimes resorted to from merely
political motives, and to have- been used as a pretext for the annoyance
and detriment of other countries;" and one of the committee, Dr. Davy,
rery pertinently remarks — "It appears to he admitted that the preven-
tive measures adopted by the governments of different Btates to exclude
a contraband trade, have been more elaborate, and organised with greater
care, with a view to efficiency, than any system of quarantine hitherto in
use, and vet with only partial sue. i — ; and this universally/"
We have -aid that we imagined every one would agree with the
conclusion of the committee which we have just referred to, but we
feel we were lamentably mistaken, tor one of the members of the
committee, and a member also, we regret to say, of the medical
profession, has submitted the following most extraordinary comment
upon the preceding part of the Report: — "It is much to be re-
gretted," writes Dr. Bryson, "that any relaxation of quarantine
should have been made, but more especially in regard of yellow
fever and cholera morbus; because, in consequence of the want of
proper precaution, these diseases, within the last 30 years, have
been introduced into countries where they were unknown before."
We really do not know what are " the proper precautions" to which
Dr. Bryson refers ; if he means to say that the strictest quarantine
has ever continued to save any country from the visitation of
Quarantine. 1 1 7
^.
cholera, we Bay, at once, thai he attempts to propagate a grievous
error, and one too that .-! rikrs at the true basis of all preventive
medicine; lie may be enamoured a- much as he pleases with strin-
gent codes of quarantine law.-, bul we are happy to think that few —
very few of the well informed, at Least, in these countries — will agree
with him in these untenable opinions, bu1 will rather take the intelli-
gible views of the committee, which certainly lead to inferences the
wry opposite to those he has expressed. The Report speaks as
follows: — " It doe- not appear that those countries in which
quarantine restrictions are most rigorous, and are mosl strictly
enforced, have hitherto been more exempt from the visitations of
the diseases against which quarantine is chiefly imposed, than other
countries where the regulations are more simple and less burden-
Bome;" and Dr. Davey adds, to the preceding, the following
comment : —
'• And some countries, certain islands in the Archipelago, under
( Ottoman rule, most exposed, have entirely escaped these visitations" !
But it is not, we contend, by the enactment of any system of
quarantine laws that epidemic diseases are to be prevented attack-
ing and spreading through a country, nor byr the most stringent
enforcement of these laws; but by the careful study of sanitary
science, and its application to the preservation of health ; and we
quite concur with the comment made by Mr Farr — that " I am
unable to assume that the introduction of dangerous diseases can
be prevented by any quarantine regulations."
The committee having come to certain conclusions from the mass
of evidence, the Report is brought to a close by some practical
recommendations, the aim being — to amend and utilise, not to
discontinue or abolish the existing machinery of action. As a
general rule, it is recommended that all vessels which have been
free from sickness, and which have no malignant disease on board,
and are clean, should at once be admitted to free pratique, no
matter from what country the ships may have come. "When
quarantine detention is deemed necessary from the existence of
malignant disease — actual or recent — a careful examination should
be made of the vessel, and of all persons on board, by the medical
officer of health; the healthy and sick should be separated, the
former not being necessarily detained, and the latter removed from
the infected ship as soon as possible. These recommendations are
humane and judicious, and stand out strongly in contrast with
existing practices, and also with some of the notions that are pro-
118
inn : :. 1; port by one ox two of the
! i tin- whole, tin; conclusions and recom-
mendation most important, practical, and in accordance with
itiuii and common - li in fact, as we might have
exp from the distinguished nun who compose tin- commitl
on quarantine. The concluding Bection we highly approve "i ; i
as follows: —
•• It would materially conduce t<» a thorough knowledge of the subject,
and probably to the Bpeedy adoption of a more rational ami uniform
practice generally, if the government of this country instituted an inv<
uion into the results of quarantine, and the working of quarantine
establishments, in the chief ports of the South of Europe and the
Mediterranean, where the system is Btill in greatest force, in order to
rtain the actual truth by personal observation on the >pot."
It' such an investigation wore made by Inmost and unprejudiced
observers, it would be soon discovered that the system, as practised
in the ports of the countries referred to, is one which is a disgrace
to the enlightenment of the nineteenth century, that it i.» nefarious,
as it is inhumane, is, and lias been, utterly useless for the purpo
for which it was designed, and, while it affords no protection to the
public health, it militates against the advancement of real sanitary
operations, and interferes with, and, in some instances, stops the
progress of legitimate commerce and national intercommunication.
We cannot close this brief notice without cursorily mentioning- the
Appendix, by Dr. Gavin Milroy, a gentleman well known as an
enlightened and strenuous sanitary reformer; this Appendix giv<
14 historical sketch of quarantine Legislation and practice in Great
Britain," and is a most able exposition of the subject, showing the
steady advancement, in this country, of sound views regarding the
imposition of quarantine as protective of the public health, until the
restrictions of that most unscientific system have become almost a
dead letter, and there have been substituted in lieu of it sensible
sanitary measure-.
It is certainly much to be regretted, that other countries, generall}' ,
have not followed our progressive example; but we trust the time is
not far distant when wise councils will prevail, and when the philan-
thropic exertions of the National Committee for the Promotion of
Social Science shall have cleared away the mists of ignorance and
prejudice which hang around the understandings of those who still
cling to the wretched fallacy of quarantine.
Hi i.ki; on the Ophthalmoscope. 110
A Practical Treatise en the Use of the Ojihiluilmosmpc. By J. W.
Hi i.ki;. F.R.C.S. Royal 8vo, pp. 77. London: ChurchilL
1861.
An instrumenl thai baa effected bo thorough b revolution in ophthal-
mic Burgery ae the ophthalmoscope must, deservedly, be an object
of mteresi to the medical profession in general, and to those members
of it in particular who have made this branch of surgical science
their special Btudy. A standard work on the ophthalmoscope,
written in the English language, has long been wanted; and although
Mr. Ilnlkc docs not pretend to fill up the vacuum with the work
we are at present noticing — laying it before the profession merely
as an elementary treatise — still it is by far the most complete that
has as yet been published on the subject in these countries, and we
shall endeavour to notice, as briefly as possible, some of its most
interesting points.
The author adopts Zander's classification of the different kinds of
ophthalmoscope, viz. : —
"1. Ophthalmoscopes in which the reflector consists of slips of
highly polished glass with plane parallel surfaces — as Helmholz's
and Follier's.
"2. Homo-centric ophthalmoscopes, concave mirrors of silvered
glass or metal — as Ruete's and Liebreich's.
" 3. Hetero-centric ophthalmoscopes, plane or convex specula, in
combination with a convex lens — as Coccius's and Zehender's. The
prismatic ophthalmoscopes, which are but little used, fall under this
elass.
In every ophthalmoscope three principal conditions must be ful-
filled : — 1. It must be able to give a sufficiently bright illumination
of the fundus; and 2. This in such a manner that the examiner's
eye can be brought into the line of the rays incident upon the eye
under examination, or nearly so, in order that it may receive the
reflected rays returning from the latter. 3. It must provide for the
proper accommodation of the examiner's eye, so that this can pro-
duce a distinct image of the part of the examined eye.
The image- seen with the ophthalmoscope are of two kinds: —
1. A real inverted aerial image, situated in front of the eye
examined; and 2. An erect, virtual, geometrical image, which may
fie in front of the eye examined, or behind it. The observation of
these inverted and erect images of the fundus is termed the exainina-
R( md Bibliographical A '
don by the indirect And the direcl method In the indirect method
the objects are lew magnified, the portion of th<- fundus Been at
once is larger, and a better idea of the relative position of iti pi
gained; this method of examination i- also the more easily
acquired The direcl method gives greater enlargement, but •
aller portion of the fundus i> comprehended in the field; it id
therefore better fitted for the investigation of minute details than
for obtaining a genera] view. Tims each method has it- peculiar
advantages, and the selection of one or the other musi depend on
the work required of it.
A- the ophthalmoscope lias been very appropriately termed an
eye-mirror — Augenspiegel — by its German inventor, bo also are the
terms employed to denote the various modes of employing it of
( . lman birth. When the examination is conducted in the original
manner, described by Ilelmholz, with a glass reflector and concave
lens — i. i ■., the upright image produced — it is styled in England, as
in Germany, examination by the upright or direct method — die
Untersuchung im aufrechten Bilde. When a metallic reflector and
bi-convex object lens are employed — t. e., the inverted image of the
fundus produced — it is called, in Germany, examination in the
inverted image — die Untersuchung im umgekehreten Bilde. This is
Btyled by Mr. Hulke the indirect method of examination. We
must confess we arc disposed to find fault with this term, inasmuch
as it scrms to us calculated to mislead the student, as if the eye
it-elf were not directly examined, but had to undergo a preliminary
or intervening process before a diagnosis could be made. We con-
sequently think that as the study of the instrument is but as yet in
its infancy in England, the more clear and unequivocal the technical
terms employed the more readily will a due appreciation of the
subject be arrived at by the student. We would, therefore, sug-
gest examination by the inverted method as a more appropriate
term.
The direct method of examination was the original one discovered
and recommended by Ilelmholz; but before we enter into an
explanation of it we shall give a brief sketch of the instrument itself.
Ilelmholz's ophthalmoscope, says Mr. Hulke, is a short blackened
metal tube, closed at one end by a plate centrally perforated, which
supports a hollow, triangular, prismatic metal box. The base of
this prism is connected with the plate by a short open cylinder, in
such a manner as to allow the rotation of the prism on the axis of
the tube. The long side of the prism contains the reflector, com-
Hulke an the Ophthalmoscope. 121
posed of three plane polished slips of glass, inclined at an angle of
56* i" the axis of the tube, die other end of which contains a con-
cave Lens, which is held in position by a friction tube. In order to
examine an eye with this Lnstrumenl tin- patient musl be placed in
a darkened room, and seated <>n a level with the examiner, the lamp
being placed on the same plane, and a little posterior to the eye
that is to he examined. The rays oflighl from the lamp billing on
the glass reflector which is held close to the eye. are reflected into
it, so as to sufficiently iUuminate the fundus, which will then present
a brilliant red colour. Some of the rays returning from the eye
under examination to the glass reflector, pass through it, others are
reflected hack again to the lamp. But as a normal eye can only
produce images with diverging or parallel rays; and as these
returning rays are converging, Helmholz was obliged to interpose a
concave lens between the reflector and the examining eye, thus
rendering them parallel or divergent, forming an erect image on the
retina of the observer. Mr. Hulke's objection to this instrument
is, that it reflects too feeble a light into the eye, so that the fundus
cannot be sufficiently illuminated. It has, however, been modified
by Edward J'ager; and Ave think that in its modified form it is
eminently adapted for the examination of all cases in which an
over-sensibility of the retina exists.
Zehender, not satisfied with the illumination afforded by Helm-
holz's ophthalmoscope, invented an instrument, also for examination
by the direct method. This consists of a convex metal speculum
in combination with a bi-convex lens, which is of shorter focal
length than the negative focal length of the speculum. The clip
which holds this lens is mounted on a jointed bracket which turns
right and left on the short handle of the speculum. A clip for an
ocular lens is hinged to the side of the frame. Mr. Hulke prefers
this instrument to that of Helmholz, as it gives a superior illumina-
tion ; he finds it, however, less easy to manage.
In the direct method of examination (observation of the erect
geometrical image), where both eyes are emmetropic, and their
accommodation is suspended, if the surgeon bring his eye very close
to that of the patient it will receive parallel or even diverging raws
from the fundus of this, which it can unite in an inverted imao-e
upon it< own retina; and this image will be mentally projected, as
an enlarged, erect, geometrical one, apparently situated behind the
patient s eye. But should the patient or the surgeon be myopic, a
concave lens will be necessary, in order to give the reflected rays
R ■ ■ wi and Bibliographical .V |
t lu requiaite parallelism or divei , and this mi placed
either before or behind the speculum
The author remarks that, in order to examine an *■ \ i* by the
direct method, the pupil should be fully dilated, and the accommo-
dation paralysed with atropine. This is not aecessar} in all
la Berlin ami Vienna there are large classes for tin- purp w of
ophthalmoscopic study, conducted by Liebreiohand Edward Jager;
ami it is only in exceptional cases, Buch as where there is an extra-
ordinary degree ofmyosis present, that atropine is had recourse t<>;
in fact the professors take particular pains in impressing on the
students the very small number of oases in which dilatation- of the
pupil is necessary.
In Berlin the inverted method of examination i> more frequently
employed than the direct. In Vienna just the opposite. Both
methods are, however, from time to time employed at each of the
above-mentioned celebrated cliniques. Still the mode of examination
at present most in vogue, both in these countries and on the con-
tinent, is by the inverted method, and the instruments most frequently
employed for this purpose are the inventions of Von Graed
assistant, Liebreich. There are two of these, a Large and a email
one, both made by Paetz and Flohr, of Berlin. The large one
consists of two tubes, one sliding within the other by a rack and
pinion. The tube next the observer contains the speculum, which
swings vertically on trunnions revolving in the clips in such a way
that it can be easily removed and replaced. A portion of this tube
is cut away, in order to admit light to the speculum, behind which
there is a narrow slit for a convex ocular lens of low power. The
tube next the patient contains a convex lens of about two inches
focal length, Bwung in the same manner as the speculum. This
tube is encircled by ;i stout collar, which slides on a vertical rod, so
that the whole can be fixed at any convenient height. The lower
end of the rod has a clamp for fixing to a steady table. Above,
the collar bears a graduated, horizontally-sliding rod, ending in an
Oval plate, against which the patient steadies his forehead. Addi-
tional steadiness is gained by a chin-rest. A small brass tube,
mounted- on a jointed bracket, forms a convenient objeet for the
patient to fix his eye upon. A couple of small blackened tin shades
cut off the direct rays of the lamp from the patient's and surgeon's
eyes. This is an excellent instrument for demonstrating cases to
a class. We have seen from 15 to "20 students, one after another,
examine the details of the ground of the eye with it, in the space
EIulke on the Ophthalmoscope. L23
ejfa couple of minutes, :» n< 1 without causing the slightest uneasiness
to tlif patient.
Liebreich's .-mall ophthalmoscope is a concave metal speculum,
one inch and a quarter in diameter, and of aboul four inches focal
length, pierced by a centra] sight-hole, the diameter of which slightly
exceed- one line. The margin of this Bight-hole is a thin blunt
edge. The Bpeculum is sel in a metal frame, t<> which a light handle
is attached; and a small dip for an ocular Lens is hinged to the
frame in BU0h a manner that it can be folded againsl the hack of the
speculum on the sight-hole.
The explanation of the mode of using those two ophthalmoscopes
is as follows: — The rays of light from the lamp, ineident upon the
metal speculum before the eye of the observer, are reflected con-
vergingly towards the patient's eye. Before reaching this they are
intercepted by a bi-convex lens of short focal length, which increases
their convergence, so that they intersect at a point anterior to the
patient's retina, and illuminate the fundus with dispersed light.
The pencils of returning rays from this circle of dispersion would meet
at a distance from the patient's eye equal to its anterior focal length ;
but, passing through the bi-convex lens, they converge to earlier
foci, and form an enlarged and inverted image, visible to an
observer's eye at the sight-hole of the speculum. In order to
explore the refracting media of the eye the speculum alone should
be used ; and the result, remarks the author, when these are per-
fectly healthy, is negative. Small threads of mucus or beads of
froth on the front of the cornea sometimes mislead persons unaccus-
tomed to the use of the ophthalmoscope ; the illusory appearances
they produce vanish when the cornea is swept by a winking move-
ment of the eyelid.
The optic nerve piercing the sclerotic and choroid, a little below
and to the inner side of the axis of the eyeball, is brought into view
when the cornea is turned slightly towards the middle line, because
this is attended by a corresponding outward movement of the
posterior pole of the globe. The colour of the optic disc and the
distinctness of its outlines depend on the amount of blood circulating
in it, on the mode in which the large vessels traverse it, the
degree of illumination by which it is seen, and Aery much on the
colour of the adjacent fundus. With regard to the shape, conieitv,
<v.c. of the optic disc there were, until very recently, a great number
of opinions on the subject, all differing more or less from each
other. Thus the term optic papilla was given to it, because it was
/,' view* vnd Bibliographical A I
one time believed that it projected into the ritreoui humour in
the form of a oone; and lome French irritera -till believe 1 1 * 1 - to be
the oase On the other hand ;i celebrated German authority
lared that, instead <>f an elevation being present, there was in
lity a depression, and he baaed his opinion on tin- result <>f j>ost
rtem examinations, Mr. BEulke Bayi 1 1 1 * - optic di
ilightli above the genera) curve of the fundus oculi, and does not
project into the vitreous humour in the form of a conical papilla,
it was formerly thought to do. Eta centre is even slightly depressed
where the nerve fibres are deflected on all sides towards the retina,
and its circumference alone is slightly raised when the aggregate
nerve bundles of the entire retina bend round the margin of the
choroidal foramen. This is the view now taken of the subject by
the greater number of writers both in England and on the con-
tinent; the depressed optic dlSOS observed at post mortem examina-
tions being in reality a diseased state, now well known under the
term excavation of the optic nerve.
The phenomena of venous and arterial pulsation which the author
states are seen at the optic disc, are seldom or never so easily distin-
guished in the healthy human eye as one might he led to suppose
from the manner in which he describes them. As a general rule
no pulsation whatever is observed in the retinal vessels of a healthy
human eye except when pressure is made on the eyeball. If we
take a healthy human eve. or the eye of an animal, and subject it
to ophthalmoscopic examination, in all probability no pulsation
whatever will be seen; if, however, we make slight pressure with
tin- finger on the eyeball, we immediately observe pulsation in the
vein, which is larger than the artery, and of a darker red, almost
approaching to a crimson colour. If we press the eyeball a little
more firmly the venous pulse becomes small, the optic disc assumes
a blanched -appearance, and the arterial pulse becomes visible. By
still further increasing the pressure we may cause the arterial pulse
to disappear completely. It was the discovery of the fact that
pulsation of the retinal vessels was the result of increased intra-ocular
pressure that led Yon Graefe to propose iridectomy as a cure for
glaucoma. In describing the red colour of the fundus of the living
eye, the author remarks that this has been ascribed to the reflection
of red lio-ht by the vascular nets of the retina and choroid, and par-
ticularly by the chorio-eapillaris, but strictly it is chiefly due to the
colouration by the choroid of the light returning through it from
the inner surface of the sclerotic. The colour of the fundus of the
HULKE on the ( >i>hth<ilmoscope. 1 '!')
\'w ing eye varies bo much in different persons thai we do not remember
to have ever examined two individuals id which it presented the
Bame identical Bhade, In the dark-complexioned inhabitant of
southern Europe particularly in Spain and Portugal — the fundus
is generally of a dark-red colour; while in the negro it presenta
almost a reddish-black appearance; in albinos, <m the other hand,
it is always of a faint pinkish colour. A< :i general rule, the younger
the person the lighter will be the colour of the ground of the eye.
We can well believe the author when he states he has hitherto
failed to recognise the ohorio-capillaris. We confess we have seldom
Been it except in persons of very fair complexions ; and even in
them it was exceedingly indistinct. When there is even but a
moderate quantity of pigment present it is altogether impossible to
distinguish the very minute meshes of this structure.
With regard to the abnormal appearances presented by the
human eye when subjected to ophthalmoscopic examination, the
author has entered fully into the subject, quoting largely from
French and German writers. There is one statement, however,
which he makes, in speaking of opacities of the capsule of the lens,
which somewhat surprises us. He says : —
" Opacities upon the anterior capsule of the lens (which itself never loses
its transparency) consist, for the most part, of lymph and pigment derived
from the iris. The pupil, when dilated, is indented, and its margin is tied
by fibrous cords, which often branch as they spread out on the lenticular
capsule ; such cords have a pearly, silky texture, or are coloured with
uveal pigment. They do not reach quite to the centre of the lens, but
start from points in a circle, which corresponds to the position of the
pupil at the time the lymph was poured out."
Mr. Hulke seems to have followed up the error of Malgaigne,
who was in the habit of exclaiming before his class, " Examinez
une capsule cristalline, chez tel cataracte que vous voudrez, lavez
la avec precaution; vous la trouverez toujours aussi transparente
que Dieu l'a faite." That this wras assuredly an error, the micro-
scope has since proved beyond all doubt; and it is now almost
universally admitted that there exist veritable opacities of the
eapeule; that is to say organic modifications peculiar to it, apart
from the opacities which adhere to its anterior face. During our
attendance £*t Professor Arlt's cfaiique, in Vienna, we had an oppor-
tunity of seeing that gentleman extract a capsulo-lentieular cataract,
both the lens and its capsule being completely opaque; and he
nd Bibliographical A ti
eatted the attention of his els i to the t-u-t that the opacity of the
capsule was Dot caused by ;mv depoeil on its anterior surface, but
was the result of an organic alteration in its structure, which be
proved l»\ firsl washing the capsule, and then placing it under the
microscope, when each Btudent present had an opportunity of
unining for himself, and forming his own opinion on the subject;
and we ourselves entirely acquiesced in the correctnesi of the
professor's statement. The Bame distinguished oculist also lays
down distinctly in his book on diseases of the eye, that there are two
kinds of capsular cataract, viz., that resulting from a depoeil on the
anterior surface of the capsule, and the other as an alteration in the
structure of the capsule itself; he has also in his possession a Dumber
of thickened, opaque, cartilaginous capsules, which he has extracted
from time to time in his practice, and which we ourselves have
a; and he states in his Lectures that a year never passes without
■al cases of the same kind coming under his observation.1
On referring to .Mackenzie's work on eye diseases we find the
following passage. Speaking of capsular cataract, he Bays: — "On
operating I have sometimes found these specks (/. e., deposits on
the anterior surface of the capsule) to separate readily from the
capsule on being touched with the needle, and to fall forward
through the dilated pupil into the anterior chamber. Inmost ca
the deposit appears to be in the membrane, not on it merely; its
texture i< thickened and opaque throughout.'1
The author gives an excellent description o\' a diseased state
known in this country by the name of " floating retina, 'b with
which, before the invention of the ophthalmoscope, we were but
very imperfectly acquainted. Alluding to the manner in which it
commences, he says: —
"It lias been very generally thought that the detaehmenl always begins
at the lowest part of the fundus, near the equator; and it may be safely
said that it i- generally firsl observed in this locality; but the possibility
always remains that the thud beneath the retina, at this part, has merely
gravitated here, having been originally poured out at a higher part of the
fundus. This is supported by a ease on which 1 observed the subsidence
of a portion of detached retina lying above the optic nerve entrance,
simultaneously with the appearance of a fresh detachment below the nerve
a Vide Arlt iiber die Krankhoiten des Auges.
b In France it is termed " decollement de la retine ;" and in Germany " Ablosung
der Netzhaut."
Qobdon on Fracture of Radius. 127
at the equator. Similar cases have been recorded byV. Graefe. And
it is probable that the occurrence would often be noticed if cases of
detached retina generally cam.' under our notice .-it an early stage. Bat
this does not commonly happen; for the separation creeps on so insi-
diously— being unattended with pain or any external signs of mischief —
that sometimes the lower hemisphere of tin- retina is stripped off from
the choroid before the patient is aware thai anything is wrong with his
; and indeed the discovery is sometimes made accidentally by closing
the sound eve.'*
Tho differenl diseased states of the eyeball, made visible by means
of the ophthalmoscope, are elaborately entered into and illustrated
in this very valuable treatise. The illustrations reflect the highest
degree of credit on both author and artist; and we can confidently
recommend the work to the profession as the best English guide
that has as yet been published, to the study of a most useful and
truly important branch of ophthalmological science.
Or the Treatment of Fracture of the Lower Extremity of the Radius.
By Alexander Gordon, M.D., L.R.C.S. Edin., &c. Belfast:
Alex. Mayne. pp. 15.
Tins is a very clever brochure on the treatment of a frequently
occurring accident. The plan of management recommended differs
from all those hitherto advised by surgical writers, and has much,
in it to make it worthy of careful consideration : —
" I have no hesitation whatever," says the author, " in stating that the
methods of treatment which have been hitherto pursued in this common
accident have failed. . . . They do not afford such a solid support
to the radius as is requisite for the restoration of its natural form ; nor,
if the form be restored by coaptation, will they maintain it until firm
osseous union lias taken place."
Dr. Gordon gives a good description of the deformity, and of the
physical signs which characterise this fracture. He passes in review
the plans of treatment described by Dupuytren and Nelaton, and
gives good reason for rejecting them ; and, at p. 8, describes his
own splint thus: —
"The splinl which I ase has attached to its radial border a piece of
wood, bo bevelled that it fills up, and fits accurately, the natural concavity
I '■ biographical A U
of (he radius. The fracture renderi the palmar rori I tins
o>ii\<-\ Instead of concave, iti normal form. The inrfaeeol ti ; i»-'l
splint u also convex, and covered with tow, a pi
ngio-piline (tin- I >«.vst material), or some other soft substance, l
iplint being thus covered is then applied to tin- fore-arm. 1 In- convexities
of the Bplint and radius are mutually brought into apposition; about ball
an inch, or perhaps a little more, of the lower end <>t tin- radius ii
unsupported, because of the alteration in its form. A thick pad, similar
to that used by Nelaton, is now applied over tin- posterior surface of tin-
carpal fragment of the radius and carpus, and over this a splint, extending
from the upper and hack part of the fore-arm to the metacarpu
He then describee the action of the splint, and gives cases to
prove its efficiency. The intention to he fulfilled by Dr. G.'fl Bplint
i- admirable, and has been carried out in the most satisfactory
manner, for many years, at the Meath Hospital, in this city, in a
much simpler, and in at least a- efficient a manner, by the plan first
introduced by the late Sir Philip Crampton. Dr. Gordon differs
from all preceding writers in recommending the fore-arm to he
kept in the prone position, but in this, as well as in the preserving
of the arch of the radius, he was anticipated by at least 30 y ear-
by the practice of Sir 1\ Crampton. The "bevelled piece of
wood" for a support to the lower portion of the upper fragment, is
highly to be commended, and worthy of adoption.
Dr. G. does not attach sufficient importance to the displacement
of the hand towards the radial side, and the projection of the lower
extremity of the ulna inwards; and there is no provision in his
apparatus for remedying this deformity. The shortness of the
under splint, and the leaving the hand unsupported is objectionable.
Certainly the upper splint, with the pads to depress the hand, will
give some fixedness to the wrist, but not such as is obtained by an
tinder splint sufficiently long to support the hand.
When the injury under consideration, long known as " Colles's
fracture of the radius,'' is treated in the following manner, it may be
so remedied that no deformity whatever will be left to point out
that the bone was ever broken.
A splint is prepared a little broader than the fore-arm, tapering
from above downwards, so as to suit the outline of the limb, and
long enough to extend from the elbow to the phalangeal extremities
of the metacarpal bones ; it is to be cut away obliquely, at an angle of
45 degrees, so that the hand, when laid upon it, is given an
inclination towards the ulnar side. There is no necessity for any
Gordon on Fracture of Radius, L29
other splint. A thin pad is laid on the splint ; then a wedge-
Bhaped compress, or cushion of lint, sufficiently large t<> fill up, or
rather (<> restore, the natural hollow which oughl to exist above the
wri.-t. is applied. The hand La then bandaged down to the Lower
extremity of the splint ; and, in recent eases, the lower third of the
fore-arm La left exposed for the application of leeches or lotions; the
upper two-thirds are fixed to the Bplinl by a roller, and in two or
three days the roller is applied continuously from the hand up to
the elbow. The advantages of this method are, that we not only
preserve the arch of the radius, and restore the; hand to its natural
position, l>ut, by supporting the hand, relieve the patient from much
discomfort, and can dispense with the posterior or dorsal splint.
A surgeon states that he tried Dr. G.'s splints, prepared exactly
as recommended by him, but the patient eould not bear them from
the want of sufficient support to the hand.
The late Sir Philip Crampton, aware of the importance of pre-
serving the arch of the radius, proposed to have splints made of
" Sparks' patent leather," or common sole leather, moulded upon
casts taken from well-formed fore-arms. These being kept of
different sizes could, with a little padding of raw cotton, or white
wadding, be accommodated to limbs of various sizes. No doubt a
well- fitting splint of this kind would be the most efficient and the
most comfortable one the patient could have. The leather should
rise sufficiently high on the radial side, to ward off the pressure of
the bandage from the bone. This object is attained by Dr. G.
thus. He says, p. 14: —
" On the radial side it (the splint) should project beyond the radius ;
and the bevelled piece for filling up the concavity of the radius should be
attached half an inch at least internal to that border. By this arrange-
ment the ulnar side of the fore-arm sustains the pressure of the bandage
or straps. The reverse is the case on the radial side. The radial border
of the splint alone is pressed upon ; this pressure forces the bevelled
portion inwards upon the concavity of the radius, and pushes it back-
wards, while, at the same time, the outer border of the radius is
protected from pressure."
This desirable object has been obtained in another way by the
following device, which has been occasionally used in the Meath
Hospital for some years, and which not only keeps the radius from
pressure, but retains the prism-shaped pad in its place: — A thin
slip of wood is secured to the radial side of the splint, and extends
VOL. xxxiii., no. 05, N. s. K
R ' ■ liographical A I
from the wrist about five inches up the arm , it should be sufficiently
ach just above the outline of the radius; this will ess*
tually protect the radius from pressure, and will throw it upon the
ulna, bo as to keep it firmly down to the splint.
Dr. Gordon deserves greal credil for tin- valuable pamphlet be
bss published, and for calling attention to this method of reme-
dying the deformity resulting from "Collet's fractun All
that we have said only confirms the soundness of bis views with
nil to the cause of the deformity, and the manner of relieving it.
We sincerely wish that bis pamphlet may have a wide circulation;
but we thought it due to him who lias departed from amongst us
to allude to the plan of treatment initiated by him, and to which
that of Dr. Gordon hears, in the intention to be earned out, so
striking a resemblance. Sir Philip Crampton, though he never
wrote an account of his plan, vet gave it a considerable amount of
publicity by practising it in a large hospital, before numbers of
students, for many years.
Manual of the Dissection of the Human Body. By LuTHEB
HOLDEN, F.R.C.S - &c Second Edition. Illustrated, pp. 576.
London: Churchill.
UNQUESTIONABLY the most reliable test of the real value of any
literary production, is its appreciation by those for whom it is
intended: hence, we judge that the demand for the Second
Edition of llolden's Manual, is a compliment far superior to any
which lies in the power of a reviewer to offer. However, the work
has been placed in our hands tor inspection, and we shall proceed
to state, candidly, the opinion which we have formed of it on
careful perusal: —
Of the general style, we have much to say in commendation.
The system of arrangement is admirable; the facilities of reference
abundant ; and the diction throughout is clear, bold, and concise ;
admirably suited for the student of anatomy, who, unfortunately,
in too many instances, is not alone daunted by the stupendous task
before him, but puzzled and disheartened by the obscurity of the
works which are intended to assist and lighten his labours.
Nevertheless, although we feel it a pleasing duty to praise Mr.
Holden's Manual, we are not, by any means, prepared to grant that
Holden's Manual of Anatomy. l.'il
it is nil the student needs t<> assist him in learning anatomy; or the
practitioner to refresh bis memory, and suggest t<> bim in difficulty.
Books and tin* knowledge they can give, as well as other aids to
science, arc viewed differently according to the circumstances, dis-
positions, and preconceived notions of the beholder. The half
fledged student sees only in anatomy and physiology the 'w bugbear11
of his final examination, and eagerly cogitates how he may "cram
u])" the requisite amount. The \a.-t majority of practitioners think
of it. merely in reference to palpable necessities, and casl aside as
superfluous, all which does not bear immediately upon daily routine.
The true disciple of Medicine, however, cannot view the study of
anatomy and physiology otherwise than as the real and indispensa-
ble key to all knowledge, and as such, pursues it untiringly, satisfied
that every advance in its elucidation, howsoever transcendental it
may appear, will infallibly confer benefit on his fellow-creatures,
and distinction upon himself. It is needless to recall instances to
illustrate the truth of this position — we would rather challenge those
who may dissent, if such there be, in real earnest, to bring forward
one single fact to gainsay it. The opinion formed of Holden's
Manual — the work at present under consideration — will vary
according as the umpire belongs to one or other of the classes of
observers sketched above. For our part, we are disposed to think
that it is best suited for a hand-book for the junior student ; that it
is less useful as a reference for the practitioner ; and wholly defi-
cient for those wTho seek to advance the profession of their choice,
by a comprehensive and philosophical study of the groundwork
upon which its fabric rests.
Mr. Holden's works, as far as they go, are remarkable for clear-
ness, and for the degree in which they simplify the subjects treated.
His w^ork on Osteology, although open to improvement in many
respects, has proved a real boon to students ; and the new edition
of his Manual will, undoubtedly, do no less in many respects. Yet,
we feel surprised that, from a work avowedly intended for students,
there are omitted a vast number of those devices which experience
proves to be valuable aids in teaching anatomy. For example,
in the demonstration of the neck, where the parts of importance are
numerous and difficult to understand in their mutual relations, we
have invariably found that, to define with brevity and accuracy the
triangles, their linear boundaries, the exact formation of their
floors, and finally, to give a concise account of their absolute
contents, properly classified, so materially aids the student as to
k 2
1 _' /,' views and Bibliographical A I
reduce his labour to a very moderate one A proper subdivision of
tain of those spaces, likewise, aids tin- learner considerably. For
unple, tin- digastric -pari' taken as a whole, from tin- number of
parts contained, taxes the memory serious!) ; whereas, if the portion
superficial to the mylohyoid muscle '><• considered apart from tin:
portion deeper than it, then the whole difficulty i- at an end. The
first is tin.' submaxillary space proper; the second i- the sublingual
The necessity for this subdivision is acknowledged in the work
before ns, by the introduction of two wood cuts, (Fige 1 ami
representing each of the spaces in question. The posterior division
of the digastric -pare, into uliu'li may be thrown the remarkable
a which accommodates the parotid gland, is glanced at but
superficially; and the relative anatomy of the great vessels of the
neek is, for the most part, given much less completely than we
consider desirable.
Passing to the description of the heart, we are surprised to find
no mention of the satety-\alve action of the right auriculo ventri-
cular valves, a wise and indispensable provision of nature, first
alluded to by Hunter, and more fully elucidated by Mr. Adam-,
oi' Dublin, and Mr. King, of London. The description of the
larynx, however, is excellent ; and the mode of explaining and
delineating the action of the muscles is most ingenious and useful.
O c-'
Looking to the dissection of the upper extremity, we find the
anatomy of the pectoral region given admirably; but, to criticise,
rather too briefly, considering its importance in a practical sense.
There exists, moreover, a strange laxity in the terms in which
the muscles arc described. For example — the subclavius muscle
is stated to arise from the cartilage of the first rib, and to be
inserted into the under surface of the clavicle; but it is not stated
at what portion of the clavicle it is inserted. The relative anatomy
of the muscular svstcm is very defective, and the action of the
\ arious muscles too sparingly described. For example — the action of
the pectoral muscles in forced respiration is totally omitted; and the
action of the capsular muscles (as such) of the shoulder joint, >hares
a like fate. Again, the remarkable mode of origin, insertion, and
obvious subdivision of the serratus magnus is passed by unnoticed. In
the description of the axillary artery its relations arc too briefly given,
and its divisibility into stages — a decided assistance to the student —
is omitted. In Fig. 44, which represents the bend of the elbow, the
semilunar fascia given off by the biceps tendon is by no means clear ;
and yet its importance with reference to venesection is considerable.
Holden's Manual of Anatomy. 133
We cannot fully approve the rule Laid down a1 this point for bleeding.
Experience in the dissecting room has shown us the great frequency
erf irregularities in the brachial artery, and we 1 1:1 \ < - come to the
conclusion thai careful palpation to ascertain its position is the only
reliable safeguard to the surgeon. Fig. 45 is n pretty diagram of
the anastomosis at the bend of the elbow, on tlie same plan OS Fig.
<, which shows the inosculations of the subclavian artery. We are
disposed to think that these diagrams would be much clearer if out-
lines of the skeleton were added. Without this they are somewhat
obscure — at least to the junior students, for whom they are intended.
The anatomy of the fore-arm and hand is admirably done, on the
whole; but we are inclined to reject the guide recommended for
ascertaining, on the undissected hand, the exact position of the
superficial palmar arch — namely, a line drawn horizontally across
the palm at the junction of its upper with its middle third. We
consider that, a much safer and more accurate indication is the line
visible on every palm, leading from the metacarpophalangeal
articulation of the index finger to the pisiform bone. The descrip-
tions of the articulations of the upper extremity are given in very
rapid style, and, of necessity, there are many omissions. Among
others we may mention that of the gleno-humeral or intra-articular
ligament of the humero-scapular articulation, a description of which
was published in the Lancet (1829-30), by the late Mr. Valentine
Flood. On turning to the abdominal muscles, we are greatly
surprised at the brief manner in which we find them disposed of.
In fact, it is beyond our comprehension how any student could learn
to understand this difficult passage of anatomy solely from the means
here placed at his disposal. The description of the anatomy of
inguinal hernia is likewise very insufficient. Obvious and palpable
layers of fascia, which form coverings, are passed without mention ;
and many highly practical points connected with the abdominal
pouches are contemptuously neglected.
Among numerous omissions hereabouts we may quote the absence
of all remark explanatory of the utility of the triangular ligament
given off from the inner insertion of Poupart's ligament, in opposing
the protrusion of a direct inguinal hernia. Moreover, strangely
enough, Mr. Holden, who appears to understand better than most
authors the true anatomy of this ligament, forgets to ascribe its
earliest notice to the late Mr. Colics of Dublin. This omission
Surprises us the more, because throughout the Manual a vast amount
of learning is exhibited in the abundant references to the various
liographical A I
author- who have mritten upon anatomical subject! To a succinct
•nut of the abdominal cavity and its content! follow- the descrip-
tion of the perineum and rgans in both * I
important portion of Mr Holden'i work i ated with admirab
mess and simplicity. We have but one fault to tin* I with it,
and that is w i 1 1 i the illuBtrations. It u true they may answer
diagrams; but we cannot sec the object of representing parti in
grotesque disproportion. The anatomy of the lower extremity it
nexl considered, and i- introduced by an excellent account of femora]
hernia. There arc certain anatomical points concerning femoral
hernia on which ire unhesitatingly differ from the author. Never-
theless, where there is any ground for discussion we would not
presume to urge our own opinions. We cannot understand Mr.
Holden when he says, that he never could find that membranous
partition between the abdomen and thigh which Cloquet described
as the "upturn orwrale." Occasionally it is badly marked; but we
have recently demonstrated it several times, and exhibited it on the
subject as plain and undeniable as Scarpa's fascia, or the deep layer
of the superficial fascia of the groin — a structure to which Mr.
Holden makes no allusion whatever. We observe other points of
dissent; but their discussion would carry our review (already some-
what lengthy) beyond reasonable bounds. The articulations of the
lower extremity are disposed of in an amazingly brief style; and
not only with omissions, but errors also. For example — there are
feral mistakes in the description of the ligament urn teres of the
hip joint. In the first place, the branch of the obturator artery
which supplies it does not go to the head of the femur. The careful
injections of llyrtl, of Vienna, have disproved that notion. Again,
the view advanced by Weber, and adopted by Mr. Holden, namely,
that the ligament is tense in the erect position of the body, and
therefore limits the movements of the pelvis, is erroneous. In the
erect posture it is absolutely relaxed. Neither does it limit rotation,
as described in the work before us, but merely rotation outwards
when the thigh is flexed. These errors surprise us, because the
student is recommended to inspect the ligament by removing the
floor of the acetabulum. Such a dissection, which was long since
made by Struthers, of Edinburgh, and Humphreys, of Cambridge,
instantlv demonstrates the errors of the description given in the
Manual.
The lower extremity concluded, the dissection of the nervous
centres — the brain and spinal chord, is undertaken. The clear and
Cooke and Watsojs mi Venertal Dissa** L35
simple manner in which this La done must strongly recommend itself
to the Learner, as well as the diagrams illustrative <>f this complex
portion of anatomy, which are original, ingenious, and useful.
[n conclusion, we feel bound to confess the general satisfaction
with which we have made acquaintance with Mr. EEolden's contri-
bution to the Literature of anatomy, and to congratulate warmly the
student commencing his Labours <>n the valuable handbook and
companion in the dissecting room now placed :it hi- disposal
On the st\le in which the book is brought out we need make no
comment. It will suffice to remark that it fully sustains Mr.
Churchill's reputation.
The Modern Pathology and Treatment of Venereal Diseases. By
Patrick Heron Watson, Assistant Surgeon to the Royal
Infirmary, &c. Edinburgh: Sutherland and Knox. pp. 39.
On the Relative Influence of Nature and Art, in the Cure of Syphilis.
By Thomas Weedon Cooke, Surgeon to the Royal Free
Hospital, &c. London: Renshaw. Pamphlet, pp. 64.
On the Successful Treatment of Gonorrhoea and Gleet, without
Copaiba. By Thomas Weedon Cooke, Surgeon to the Royal
Free Hospital, &c. London: Renshaw. pp.32.
The first pamphlet is a reprint of a very able review, which appeared
in the Edinburgh Medical Journal, some time back. It consists of
two parts — the first, which treats of gonorrhoea, will meet with very
general approbation. The views of John Hunter on the identity
of the gonorrhoeal and syphilitic poisons, are now being so univer-
sally given up as untenable, that no laboured argument is needed
to overthrow them. The purely local character of gonorrhoea and
its incapacity to produce chancre by inoculation, are now accepted
points. Almost equally accepted is the fact, that every portion of
mucous membrane is capable of gonorrhoeal inflammation, and that
wherever it commences in the urethra it is liable, if unchecked, to
pass back through the entire canal, and thence, by the vas deferens
to the epididymis; differing nothing in this from any other inflam-
matory affection in the neighbourhood, for we not unfrcquently see
orchitis resulting from inflamed prostate or bladder. Holding these
Bibliographical A I
we fully, it i- natural that the bent of hii (Watson's) mind,
ihould be towards a local treatment, and that lit- recommendi the
use of astringent Injections, largel) diluted at first, ami in< I in
'li a- tlu- diminution <>f irritability ma\ dictate. Still he
clings, Bomewhat needlessly, a- we think, to tin- "dirty, nauseous,
ami permeating drugs, copaiva and cubebs," attributing to them,
however, only tin- local action through the urine, which Ricord has
demonstrated to belong to them. In gonorrhoea] ophthalmia he
adheres to Guthrie's ointment, and the solid nitrate of silver pencil;
tor ourselves, we have Been more benefit from a half hourly injection
of a very weak solution — gr.<|,or even Less, to the ounce — than from
the heroic plan; nor can we understand why a weak astringent ifl
recommended in the case of the urethral inflammation, and a Btrong
one for the same condition in the conjunctiva. The results, how-
i\ are the grand test of a theory; and since we have nut in
practice the repeated weak injections we have never lost an eye,
thoimh dealing with some eases of formidable severity. The rule
which we have more than once laid down, with reference not only
to gonorrhoea!, hut to all inflammation, and to the internal as well as
tlu- external application of remedies, is — the more acute the inflam-
mation, the more diluted and the more frequent should the applica-
tion of the remedies he; and the more chronic the inflammation, the
Stronger and less frequent. This rule approaches to a law in its
invariable certainty, and is applicable to a multitude of cases which,
at first Bight, have no apparent connexion with one another.
We now turn to Mr. Watson's second part, which treats of
Byphilis. If Carlyle has truly said that the History of the French
Revolution has been written in hysterics, with how much greater
truth may this he said of syphilis. No man seems to approach
Byphilis content to observe, and not to generalize. Mr, Watson is
no exception — he dogmatises with a vengeance — he is a strenuous
upholder of the doctrine of the diverse nature of syphilis. In his
pages we find very pretty descriptions of fc- The simple soft non-
infecting chancre ; and the indurated, the infected, the Hunterian
chancre, the chancre proper, with its inevitable syphilitic infection."
The characteristic suppurating bubo of irritation, which accompanies
the former, and the gland or glands of stoney hardness which are
the mark of the latter, are also very neatly described. Destruction
by powerful caustics is recommended for the one sore; a prolonged
exhibition of mercury for the other. A denial of a power in
secondary syphilis to infect, is also prominently put forward. The
CooKi; and Watson on Venereal Diseases. 137
only possible objection to such pretty theories, u their inconsistence
with every-day facts— but, even here Mr. Watson is triumphant
Has any man observed secondary s\ philis resull from a soft chancre?
forsooth he has overlooked the bard stage, or a concealed chancre,
or a former infection! for your hard chancre is i frail and fickle
thing, here to-day. and gone tO-mOlTOwl EJaS any one observed
an undoubted hard chancre not treated by mercury, and not followed
by secondaries; -till, there is the loophole that his hard chancre
was hut a soft one. with a base of inflammation. Has any one seen
a child with congenita] syphilis, poison its nurse's breast by means
of aphthous excoriations, which are certainly not primary son
Mr. Watson wisely stops short of such discussions, and goes off
on another tack, disdaining to notice so puerile an objection to his, or
rather Ricord and Bassereau's theory. Many men can theorise
beautifully, but bring them to the test of treatment, and they fail.
It is not so, however, with Mr. Watson — while his theories are but
rechauffes of the French School, his practice is soundly based, and
may well be listened to by those who still dream of specifics ; not
that we accept it as our credo in its entirety, for who ever yet
agreed thoroughly with the practice of another; but generally, it
bears the stamp of sound science and good common sense. He
says, " we do not claim for mercury any specific influence by means
of which it follows out the syphilitic virus and neutralizes it ; nor
do we maintain that, in order completely to extinguish the diathesis,
it only requires that a certain indefinite quantity of mercury should
be given. We merely claim for mercury an eliminative power, by
means of which a rapid metamorphosis of tissue is effected, and the
symptoms of syphilis are hurried through their regular evolution by
the elimination of those modifications of tissue, which the introduc-
tion of the syphilitic virus has produced." This is the key to his
treatment, one precept of which will suffice: — "Wherever the
gentlest possible physiological effect of the mercurial has occurred,
then the full therapeutic effect has been attained; and anything
further must be injurious. Whenever the gums become tender, our
eliminative ultimatum has been reached; and all we can hope to
gain by the employment of the remedy will be attained, by keeping
up this condition for such a period of time as it seems to act, by
improving the general health of the patient."
We must now turn from Mr. Watson to Mr. Weedon Cooke
whose theoretical opinions are, in many respects, diametrically
opposed to those we have just considered. He not only declares
Bib liographical A
boldlj that " The Individual and not the rirus, govern the oharai
of the chancre, and, at the same time, determine! the acceptance of,
or the resistance to constitutional Bymptoms;" but proves bis point,
in the vrords of liict.nl and Henrj Lee. The former surgeon
■ays iii his lectures, •• 1 think it maj be inferred that, for the
manifestation of constitutional syphilis, certain peculiarities lying
within the individual, which have as yel escaped detection,
indispensable; and that syphilis is, in this respect, on ;i par with
other contagious di» The latter surgeon may be looked
upon as one of the great exponents of the French theories in
England; and the following opinion given forth by him in Mr.
Holmes1 A System of Surgery, is of great importance in its
bearing upon the question of diagnosis between infecting and non-
infecting sores. *• We have at present no generally recognised and
well-denned mark of distinction, independent of inoculation, between
those diseases which are syphilitic and those which are not." Al
contrasting the views of two Ricorditee on a vital point of their
theory, let ns quote again from Mr. Watson and Mr. II. Lee: —
The former Bays, " Induration is always an early symptom of an
infecting chancre; it' a chancre is to he a source of infection, the
induration will appear about the third and rarely later than the
seventh day after the commencement of the sore; but having onee
appeared, unless developed in a very characteristic degree, it may
be evanescent;" "often," as Eticord says, " disappearing before the
work of reparation is finished, and before cicatrization is complete."
The latter, as quoted by Cooke: — "Infecting chancres do not
generally show their specific characters for some time; even a
month has elapsed before the induration has appeared." Like the
cats of Kilkenny, celebrated in song, Ave may hang these observa-
tions side by side, content to let them annihilate each other.
Mr. Cooke further holds, that the skin is the proper organ for the
elimination of the syphilitic poison — he conceives, "that mercury
retards the natural cure, and substitutes a not innocuous means of
relieving the symptoms for an uncertain period ;" hence, relying on
his own experience, and claiming to have seen "several thousand
k-a-c* of hard chancre and its consequences;" he inclines strongly to
chlorate of potash, and dilute hydrochloric acid, in doses of fifteen
grains of one, and twenty drops of the other, in water ; or infusion
of Columba or gentian ; limiting his use of mercury to sluggish
bilious temperaments, when he may add a few grains of blue or
Plummers pill, for a few nights only. Iodide of potash he com-
Cooke and Watsoh an Venereal Diseases. 139
mends only lor periosteal pains; for local treatment, lotions of
OOpper, rino, or lead, and black wadi. wit 1 1 gentle friet ion of* bine
ointment, for a few nights, when the nicer is healed, to disperse the
hardness, either local or in the groin. The hot air bath, the
mercurial vapour hath, (stopping short of the specific action of the
mineral,) with good diet, and warm clothing, &c., are to complete
the cure. In fact. Mr. Cooke is as strong an anti-mcrciirialist as is
possible lor a man to lie in the present day; and we fear he gOCS
even a little further in this direction than we can follow him — not
a- regards the majority of cases of syphilis, which, after all, need
mercury no more and on no other principle than do other diseases.
With Mr. Watson, we believe, most men of sense now scout the
notion of mercury as a specific, in the sense of its being an antidote
to the venereal virus, and prescribe it, whether largely or with
discretion, as an eliminator of effete and poisoned structure; but
there is no denying the fact, that in one form of the disease, the
congenital, (of which, by the way, Mr. Cooke says nothing), mer-
cury is the only means at our disposal of effectually rousing the
eliminating organs; and, even in some forms and constitutions,
where the drug has been injudiciously thrown in, a state of system
may have been induced, in which no other stimulus will call these
organs into action. In such cases, and they are very melancholy,
no relief will be obtained from severe suffering, without a further
use of the very drug which has to answer for much of the existing
mischief. These cases, however, are now rare, and bad tertiary
symptoms would be a disgrace to surgery, were it not, that in most
instances it owes its existence to the cupidity and folly of the
unlicensed quack and his miserable victim. Few men owning and
deserving of the name of surgeon, will now venture to submit their
patients to the dangers of a six-months' persistence in the use of
mercury, or even to a six-weeks' course of the drug, in the old
acceptation of that term. In these views of the disease and its
cure, we are but reverting to what Cullen long since propounded
in his work on the Materia Medica ; here, with true philosophy he
lays it down, that the disease is to be eliminated by increasing the
natural secretions of the body; and he recommends mercury on this
ground alone. We who possess many other less dangerous weapons,
can afford to lay it comparatively aside; but, because the majority
do not require its administration, we must not flatter ourselves that
we can cure the disease in all cases without it.
Mr. AVeedon Cooke, on gonorrhoea, may be dismissed in a few
140 B liographieal A I
irordi II renders tin* urine neutral t»\ a free nee of alkaline
eta lit I in this manner of th<- ardor orinas and chord
and then oures the running with solution of chloride of zinc, varying
in strength, from half a grain to three grains per ounce He r<
pfoperl) denounces nitrate of silver injections; has ao opinion of
oubebs and copaiva, as internal remedies. \\ » have no1 prescribed
either for many years; and trust, almost entirely, to well regulated
injections, generally of alum. No injection should be used which
does not coagulate the albumen of the purulent secretion; for, tip
are cases on record, in which cystitis has followed a warm water
injection, which had sent on into the bladder the infection- pus
from the urethra. From three days to a week, are sufficient to put
an end to an ordinary gonorrhoea, by well-timed injections. ( tcca-
Bionally, in first attacks, some nauseating doses of tartar emetic will
be required for bringing down excitement, and some alkalies to
counteract the ardor urinie ; but in most cases we can cure the
disease by local means alone.
In taking Leave of these somewhat remarkable pamphlets, we beg
to recommend them for perusal to all who are brought into contact
with syphilitic practice; they will well repay a careful perusal, and
contain more valuable matter than many an imposing quarto.
M mortal de Therapeutique. A Image ties Me'decins Praticu
Par le Docteur F. Fot. Paris: Germer Bailliere. 1862.
Memorial of Therapeutics for the use of Practical Physicians. By
Db. F. Foy. Paris: Germer Bailliere. 8vo, pp. 1225.
For some years past we have been labouring under the impression
that the inhabitants of Great Britain are the principal worshippers
at the shrine of Quackery — that the altars of the god receive its
richest contributions from our fellow-countrymen, and that England
is the Empirics Arcadia. Nor need the opinion that we entertain
be wondered at, when one reflects on the number of advertisement-
that appears day by day in our public journals, emanating from so
many different quarters, each and all of them vaunting the particular
Doctor So and So and his stuff, the one as the incarnation of all
human medical knowledge, the other (to use the mildest appreciative
expression) as the Elixir Vitae. Have you corns? try such and
such pills ; they will not only cure your corns, but give a fascinating
Foy on Therapeutics. Ill
expression to your face, make your hair curl, and impart to you an
inexpressible air of supremacy and command. Save you constipated
bowels? win- try Mich and such a mixture (N.B. the bottle at 33s.
far more effective than thai sold at 2s. '.'. ',<!.), it cures aot only this
complaint, bul sterility, piles, coughs, fit-, and, beyond all, that
which has puzzled all OUT bed authorities to do -consumption. To
find one medium capable of curing every variety of venereal disease,
has, in modern days, been solved by the fortunate and learned
discoverers of the " Ilcach-.-o-f'ar," and some two dozen other equally
fortunate investigators; and, independent of these philanthropists,
Bhould their remedies unaccountably fail, have we not mesmerists,
table-rappers, electro-biologists, bio-phrenologists, homceopathists,
hydropat lusts, and every other variety of trickem-opathists, to fall
back upon, to relieve medical science at the present day of the
opprobrium of not being able to cure every disease brought on us
by human folly, inheritance, or misfortune. Men, no matter with
what little amount of brains they may be endowed, would hesitate
ere they entrusted their fortunes to the tender mercies of a legal
charlatan, but their lives are fearlessly, nay recklessly, committed
to the care of any mountebank who has but the effrontery sufficiently
to advertise himself and his wares. No wonder, therefore, that we
should exclaim " Vive la bagatelle, England for the English, but
the English themselves for the quacks."
Now, if Great Britain be the Eldorado of Empirics, France is
the land par excellence of simples. In no other country on the face
of the habitable globe is such reliance placed on remedies of no very
apparent if not of questionable energy. And in the work, the title
of which heads this article, we find a grand exposition of each and
all of these. Nor is our author content with giving us formularies for
these ; his ambition is of a more vaulting character ; it is presented
to us as an encyclopaedia of medical knowledge. In alphabetical
order we have presented to us the names of every disease to which
flesh is heir, and of all the resources of a most copious Materia
Medica.
To give our readers some idea of the manner in which our author
has acquitted himself of his self-imposed task — herculean almost in
its contemplation — we shall open the book at haphazard, and submit
some extracts for their consideration : —
" Dislocations of the Fibula upon the Tibia — Very rare disloca-
tions."
1 l_' R nd Bibliographical A
\\ , tru ' thai our readers will not think ui imposing on their
lulitj when w them thin extra ithful tran
of M h- Docteur Foy'i clear, full, and explicit description! and
instructions on this form of surgical accid<
A _iiiiii —
•• Poi r*§ Disbasb, or Vertbbbal Diaaui — Local an I J symp-
toms— Destruction and suppuration of the bodies ol the *erl ith
gibbosity, inflection, and ourvation of the spina] column, inconveniej
in the movements and position — disturbance in the circulation and
piration, abscess by congestion, &c, according to the seat of the
disease — abscess when the disease occupies the dorsal and Lumbar portion-,
rare in the cervical region.*
His remarks on aneurism arc so happy and exhaustive, that wo
should not consider ourselves as having discharged our duty to such
of our professional brethren in this city as have enriched this
department of surgical science with their labours, did we not record
them here tor their special edification: —
" Aneurism of the Brachial Artery — Symptoms — compression of
the radial and median nerve, whence the semifiexion of the arm, the pains
in the fore-arm ami hand, &C."
Hear this ye shades of Porter and Bellingham ! read this Tufnell,
and blush at all the time and paper you have wasted, when the task
could have been completed in two lines and a half — and such a twro
lines ami a half!
Again —
"Aneurism of the Femoral Artery — Symptoms — tumour suddenly
developed, of a round shape in the upper part of the thigh, of a flattened
one in the lower part of the limb, &C*
&C. ! We have all heard much of Lord Burleigh's shake of the
head, and of what a world of meaning was therein; but did any of
us ever know of so comprehensive an &C. as this of M. le Docteur
Foy? In it we must look for all that we should know of the
diseases which he pretends to describe — in using this word
" pretends," we do so advisedly. A more outrageous insult could
not be ottered the members of any profession, than to put forth such
a work, under the pretence of its being an exposition of the present
Fot on Therapeutics. 1 48
position of medical and Burgical knowledge is any civilized country,
and. as il were, to add in-ult to injury, in his preface lie states this
precious work to be an epitome of the labours of the most distin-
guished of our continental brethren. In his preface he writes
thus : —
"In this work, the fruit of twenty years of study, and of ten years of
practice, we have described all that we have learned from Pinel, Landre —
Beauvais, Corvisart, Petit, Chaussier, Bosquillon, Montaigue, liiett,
Alibcrt, Laennec, Magendie, Ilusson, Cullerier, Lherminier, Honored
Portal, Cayol, Itard, Esquirol, Leroux, Fouquier, Double, Recaniier,
Baron, Desormeauz, Guersant, Pelletan, Boyer, Dupuytren, Sanson,
Dubois, Marjolin, &c, all able and celebrated professors.
"Since this period, 1843, we have placed under contribution the lec-
tures, memoirs, monographs, and observations of the pupils and successors
of the great masters whom we have just enumerated. To say that we
have largely borrowed from all those who now-a-days occupy the foremost
rank in the art of curing, is but to proclaim the intention that we have
had of placing our work on a level with the science."
To state that he has faithfully given us all that he has learned
from these great ones of the past, may be perfectly true ; but to put
this farce of a book forward as a sample of the present position of
French medical science, is an insult to the talent and acquirements
of a nation, to the scientific members of which we lie under too
many and deep obligations, for us to pass it by in silence. Had he
contented himself with giving us the formularies of the celebrated
men, whose names he invokes to shield his compilation, we might
have expressed a different opinion of his work ; true, it would not
be original, still we should have been grateful for his labours, and
expressed ourselves accordingly. In it we find many formularies
suggested and employed by these celebrated men, to whom in his
preface he alludes, and it was the finding amongst those such a
quantity of Siropes, tisanes, &c, that suggested our remarks on
the taste displayed by our continental brethren for such simple
remedies. Had M. le Docteur Foy confined himself to the collection
and recording of such, we again repeat it, his work might have been
tolerated ; but even then it would have been inferior to many similar
works long since placed at the service of the medical profession;
but gravely to put it forward as a synopsis of medical and surgical
science, is an assumption at which we are at a loss to know whether
to laugh or be indignant.
1 i i nd Bibliographical A I
i an Chemistry. Bj M w\\ 1.1.1. SlMPSON, M B I ( D
Formerii Lecturer on Chemistry in the Park-street, and the
Original Schools of Medicine, Dublin.
/ . ■ / neue Methoden zur Bestimmung •
ischen and unorganischen Verbindungen. Annalen da- Chemie
and Phannaoie Bd ic\ , p. 63.
\ U coneemant ruction du Brome sur VIodure cfaldSk
( imptes Rendus, Tome xlvii. Seance dn 1 Mare, L858
Sur une base nouvette obtenue par ruction de Vammdniaque sur le
tribromure tfallyle, Annales de Chimie et de Physique, 3rd
Le, t. lvi., and Philosophical Magazine, Oct., 1S58.
Action du Chlorure tTacStyle sur ValdShyde. Comptes Rendes,
Tunic xlvii. Seance du 29 Novembre, L858.
On t/w action of acids on Glycol. Proceedings of the Royal Society,
Nob, 34 and 36, 1859.
On the Synthesis of Succinic and Pyrthtartaric Acids. Philosophical
Transactions, 1861. p. 61.
The Medical School of Trinity College has been deservedly in
possession of a high reputation for many years, and the study of
experimental physics attracts more students at the University of
Dublin, than at cither of the sister Universities. Of both medicine
and physics, Chemistry forms a most important part. We do not,
however, see that, as regards that science, until the appearance of
Dr. Simpson's papers, much has been done by any one, with the
exception of Professor J. W. Mallet, of late years to remove the
name of •• silent sister, " so often applied to our alma mater. There
are no opportunities offered to the students of chemistry to advance
their studies after they have taken out their degree, and until
facilities for this purpose be provided, those who determine, in spite
of difficulties to pursue the study, are obliged to repair to the
Universities of France or Germany.
Of those who have followed this course, few have devoted them-
selves to the study of chemistry alone, and of these Dr. Simpson
has distinguished himself by the variety and importance of his
researches, as a glance at the foregoing list will show. We hail
Simpson's Papers on Chemistry. 14.")
these publications with the greater pleasure as they appear to
increase in importance with every year, In fact, the latest of the
papers, thai on the synthesis of succinic and pyro-tartaric acids, is
that which has in itself the greatest intrinsic value and it affords us
earnest of similar investigations being carried further and with still
greater results hereafter.
We first find Dr. Simpson at work in the laboratory of the
University of Heidelberg, under the auspices of Professor Bunsen,
whose instruction has been sought J>y so many of our English
chemists. He is engaged in the examination of certain azotised
bodies which are very difficult of combustion. lie finds the ordi-
nary oxidising agent in organic analysis, oxide of copper, insufficient
to complete the process of liberation of nitrogen; and, as the use of
eliminate of lead is impracticable, from the nature of the analysis to
be performed, he is driven to seek for a substitute. The method of
combust ion with soda lime is unfitted for the purpose, in conse-
quence of some peculiarities in the constitution of the substances
under examination. He therefore tries the red oxide of mercury,
instead of oxide of copper, and finds that it gives results which
leave nothing to be desired. He gives two methods, of which
one is comparative, the other absolute. The latter he finds appli-
cable to the analysis of all the compounds of nitrogen, without
exception.
AVe cannot attempt to give a description of the processes, but
must refer our readers to the original paper, as, without the plates,
it would be impossible to give an intelligible account of them.
They have been thoroughly tested by Messrs. Gibbs and Genth
(Annalen der Chemie, vol. civ., pp. 150 and 295), who have per-
formed upwards of 30 analyses by them, which are remarkable for
their accuracy. They are also incorporated in the last edition of
Freseniuss Text Book of Quantitative Analysis, in which none but
trustworthy methods are inserted. Nevertheless, we are of opinion,
that, with the exception of the cases where the experimenter was
precluded, as Dr. Simpson was, by the circumstances of the case,
from employing the methods either of Liebig, or of Will and
Varrentrapp, the processes he recommends will hardly meet with
general use, as they require a good deal of manual dexterity in the
fitting of apparatus. This, however, does not detract, in the least
degree, from the originality and fertility of resource which are
exhibited throughout the paper. Several of Dr. Simpsons subse-
quent investigations have been carried on in the laboratory of M. A.
VOL. XXXIII.. No 65, tf. 8 L
IS
nd Bibliographical Notit
\\ urtl, in Paris, and haw ;i reference, more Of li *fl direct, tO the
ciiul prop af the poly-acid alcohols, for vrhich that
mist is bo j u-tly famous. The first iras carried on with the
forming a glycerin, corresponding to ordinary alcohol,
from the iodide of ethylene This substance, whose constitution is
(\lljl,, yields a compound C4HSI, which is the iodide of acetylene.
From the homologue of this body, belonging to the propyl
M. Wurti has obtained the terbromide of ally] C6HflBr„ and
from it has ultimately obtained ordinary glycerin, (\IH>„ Dr.
Simpson Bucceeded in forming a body which had the same com-
ition (C4H3Br8) as that Bought for, with which, however, it i-
only isomeric, as its true rational formula ie C4( o8iBrt. It
the brominated bromide of ethylene, and docs not, therefore, cor-
respond to the terbromide of allvl obtained by Wurtz.
Dr. Simpson next proceeded to carry on experiments on the
terbromide of allyl, above-mentioned, and, by the action of ammo-
nia on it, succeeded in forming a new organic base, which is di-brom-
fC,H4Br
allvl-ammonia. Its formula is N< C6H4Br. It is, accordingly,
(h
an imid base, in which the two equivalents of hydrogen are
replaced by an equal number of equivalents of the mono-basic radical
( H4Br, (brom-aJlyl). The formation of the base was accompanied
by the separation of bromide of ammonium in large quantities. In
Dr. Simpson's first communication on this subject {Comptes Rendust
xlvi, p. 785), he was inclined to write its formula ^"w^ii5p.
According to this view it would be an ammonium in which the four
equivalents of hydrogen are replaced by two equivalents of the
bi-basic radical C\, 1 1 -, 1 >r. A radical of this type CnHn is found to
be bi-basic, while those of the type r„llll+| are mono-basic. He
was, however, disposed to alter his views on the subject, by the
discovery that the body under examination contained, at all events,
one equivalent of replaceable hydrogen. On treating the base with
iodide of ethyl, Dr. Simpson formed the hydriodate of ethyl-di-
brom-allyl-ammonia. This base has the composition N
and it has strong alkaline properties, being able to precipitate the
Simpson's Papers on Chemistry. 117
oxide of copper from its sails. Dr. Simpson was unfortunately
unable, owing to the paucity of material, to complete bis researches
in this direction by the formation of a base corresponding to am-
monium.
The next paper which we have to aotice is very brief, it merely
gives the result of an experimenl made with a view of forming
crotonic acid by synthesis. This acid is the second member of what
is called the " oleic acid group," the typical formula of which is
CnHn — ._,(),. The best known members of the group are oleic acid
C86H8404 and acrylic acid C6H404. The former is the essential
acid constituenl of almosl all so-called oils. All acids belonging to
this group are decomposed, on being heated with potash, and yield
acetic acid among other products. Acrylic acid yields acetic and
formic acids, as C6H404 + 2HO = C4H302) n , C2HOa\ n
Reasoning from these data, Dr. Simpson tried to form the next
highest acid to acrylic, viz., crotonic C8H604, by the action of
chloride of acetyl on aldehyde. He tells us that he was led to make
the experiment by the fact, that Bertagnini has formed cinnamic
acid C18H804 by the action of the oil of bitter almonds on the same
chloride. In Dr. Simpson's case the experiment did not yield the
desired results, as the bodies employed combined together without
the elimination of hydrochloric acid, as he had been led to expect
would be the case. The compound produced had the composition
C8H7C104, and Dr. Simpson was enabled to assign to it its true
place and name in the course of his researches on glycol, which we
now proceed to notice.
These investigations possess an interest far superior to that of
any of those above noticed. The whole theory of poly-acid alcohols
is of very recent date, and is, to a great extent, due to the labours of
M. Wurtz. In the laboratory of this chemist, Dr. Simpson per-
formed a series of experiments on glycol, the bi-acid alcohol,
intermediate between the ordinary alcohols, which are mono-acid,
and the glycerines, which are tri-acid. The most interesting
compound which he obtained was one which is isomeric with that
produced in the experiment last cited, and whose empiric com-
position is accordingly CgH7C104. It is the " chlor-acetine of
glycol," and is intermediate between Dutch liquid and the di-
acetate of glycol. This is seen by a glance at the following
formula? : —
L 2
I I ^ B biographical A
C4H,Oj Ul I II 03 [04
Dutch Liquid CI C4H,Oa J
Chlor-aoetine of Glycol Diacctate of Glycol
(Simpson) (Wurtz)
The bodj isomeric with the chlor-acetine of glycol, which hai
been above referred to, ii called by it- discoverer u chlor-acetine of
ethylidene," and belongs to the series derived from tin- hypothetic
hydro-carbon ethylidene, isomeric with ethylene (defiant gas). The
former of these series contains aldehyde, while the body isomeric with
it in the ethylene series is the oxide of ethylene, or ether of glycol,
obtained by Wurtz. Dr. Simpson has followed up his discovery
by the successive formation of a homologous compound, containing
the radical butyroyl, and also of one containing benzoyl. He point-
out a process by which the two equivalents of replaceable hydrogen
in glvcol may be replaced by acid radicals, and has actually obtained
C«H< )
the butyro-acetate of glycol. C4H80j ; 04.
c8h7oJ_
We now eonie to the last and most important of Dr. Simpson's
investigations. There are two homologous series of monobasic acid-.
whose typical formulae are respectively CBHn04 and CnIIn 804.
Parallel with these, we find two series of bi-basic acids, represented
by the typical formula' CBHn.808 and CnHn 10O8. The first-
named acids arc directly connected with two series of the mono-
acid alcohols, and it has long been suspected, that a similar relation
existed between the bi-basic acids and the bi-aeid alcohols or glycols.
The credit of establishing the correctness of this surmise, belongs
to Dr. Simpson. It has long been known, that the cyanide of
an alcohol radical will yield, on being heated with caustic potash,
the acid of the next higher alcohol, with the elimination of ammonia.
By the use of this process, Becker has succeeded in forming the
missing acid margaric C\,1I;U(), from the cyanide of cetyl, and.
theoretically speaking, we ought to be able to obtain, successively,
all the acids and alcohols of the CnHn+1 group from formic acid,
were it not that the process of producing an alcohol from its own
fatty acid is a very troublesome one.
Dr. Simpson first formed the bi-basic cyanide of ethylene
C4H4Cy2, a body which had never before been prepared, and
treated this with caustic potash. The reaction which took place
is represented by the following equation . —
Dobbll on Germs and Vestiges of Disease.
L49
C4H4(C,N), +2(KO.HO)+4HO= C8H4041 q^NH,
Cyanide of ethylene Succinate of Potash.
Dr. Simpson carried his researches further, and succeeded in
forming the next higher bi-basic acid, pyro-tartaric C10H8O8, by
treating the cyanide of propylene C6H6Cys by tin- same process as
he had used with its homologue, the cyanide of ethylene.
This fact directly proves thai the succinic acid group is directly
connected with the hi-acid alcohols (glycols), and both are traceable
to a series of bi-atomic hydrocarbons CnHn. The relations arc
Strictly parallel to those of the ordinary alcohols and fatty acids,
as may be seen from the following table: —
Mono-acid
Mono-basic
Bi-acid
Bi-basic
C4H5)0
Ethyl alcohol.
Propyl alcohol.
C6H5021 0
Hju2
Propionic acid.
C8H7021 ^
Hju2
Butyric acid.
C4H4I ^
Ethyl-glycol.
H2/U<
Propyl-glycol
C8H404\ r>
H2/°4
Succinic acid.
Pyro-tartaric acid.
We do not hesitate to characterise this, as one of the most im-
portant discoveries which have been made this year. The nature
of the papers which we have been examining, is such, that they
do not well admit of criticism. They are simple statements of
observed facts, and their bearing on other investigations is therefore
easily shown. We have therefore deemed that the task of review-
ing them would be best performed by giving a brief abstract of the
contributions to chemical knowledge afforded by the author of the
papers.
Lectures on the Germs and Vestiges of Disease, and o?i the
Prevention of the Invasion and Fatality of Disease by Periodical
Examinations. By Horace Dobell, M.D., etc., &c. London:
Churchill. 1861. 8vo, pp. 198.
It is not very easy to avoid doing Dr. Horace Dobell a very great
injustice, and that, by taking his words from his own mouth at any
one part of his lectures. Dr. DobeU Is a man who evidently i
think, and not (infrequently to rery good purpose; but, not
unseldom with men of good abilities hut somewhat defective
training, he is at times as enthusiastic for a worthless plagiarism
for an entirely original idea. He has got to that stage of mental
cultivation, whereat what is merely pseudo-scientific, i idered
legitimately available for purposes of dilution; and p ing an
ive fondness for the first fruits of bis brain, he imagines that
his darlings will be more tenderly dealt l>y, and more affectionately
ived, through a bestowal upon them of grandiloquent appella-
tives, leading at least to the inference that their connexions are
undeniably good.
Of a verity we believe, that were we not one of the most astute
at pre -lit wielding the critical pen, Ave should have
down this book at once as one of those deceptive pieees of flimsy,
passing muster only among a certain set of people, and credited by
the lights of scientific institutions, by raw disciples of Comte and
Miehelet, and by the ladies who read at the museum in blue
stockings and spectacles, with a capability of setting fire to the
Liffey. There is that ingenious dovetailing of semi-scicntitie scraps,
ami so cunning a torturing of intricate phrases, that, as we have
said, we began to think the whole thing was a sham. For we
have an abhorrence of the growing vice of dealing with life from
the equational point of view, which looks so very well on paper; of
analyzing by simple mathematical rule whatever is subtle, inexact,
and poetical in science. The phraseology of the X + Y school is,
to us, cacophonous. We have a distaste for all such terms as coeta-
neous, correlative, anteeedental, concurrent, quantitative, and the
like, which glitter throughout the text like false diamonds on the
shore, while the broad blue bosom of the ocean of truth spreads out
so invitingly. Not but we are glad to find Dame Physic in good
company, and getting on in the world ; but she must be sparing of
too free a use of the language of her betters, and be rather chary
of the abstract and the concrete, the esthetical, the co-ordinate, and
so on. " Madam," said O'Connell, to a female compatriot of our
own, " you are a parallelopiped," and that was enough for her. Dr.
Dobell talks of vitalized germs, antagonistic developments, and vital
ultimatums, and is, we confess it, at times more than enough for us.
But to return to the shingle —
" According to the most recent statistics employed by actuaries, it may
Dobbll on Germs and Vestiges of Disease. 1.~>1
be calculated, thai out of every 100,000 children born, only 68,296 reach
the age of twenty-five jrears; 86,704 dying from various causes before
thai age. If each of these 68,296 individuals has, a1 the age of twenty-
five, produced one child and foths, the mi ml km- thus obtained will be only
a fraction more than is sufficienl to compensate for loss, and to bring the
population up to the original quantity. In order, then, to keep up the
population, tlu> Y..M.F., with which each individual was endowed at
birth, must have accumulated a1 leasl &ths during life, instead of wasting,
expending, or being consumed ; otherwise, the individuals of each suc-
cessive generation, would l»»i endowed with a smaller quantity of force
than their predecessors* And as, so far from the population being only
maintained al a fixed quantity, it increases at a great rate, the accumu-
lation of V.M.F., must he proportionately great. To fulfil this necessity
of organic existence, we discern — or at least such is my hypothesis — that
every living thing is given, 1st, a certain endowment of V.M.F., with
which to begin its career ; 2ndly, accumulators of fresh force ; the amount
which it can thus accumulate being regulated only, caieris paribus, by the
requirements of the ultimatum."
The author in this paragraph intends to convey that the vital
principle is derived and accumulated from the inorganic world ; and
that the amount of this principle or force transferred to the living
being by its own organic actions, is proportionate to the necessity
that claims its exercise in the external world, and which originates
in the loss it is intended to compensate. That some species of
transference does take place, is in harmony with the periodic demand
every organised being sets up for nutrition; and it is scarcely a
violation of analogy to suppose, that in the progress of the consumed
material, from the condition of proximate principles to constituent
elements, a condition or force transfers, (which may be estimated by
the increase in vital and vitalizing phenomena, and the evident
direct dependence of these upon the amount of food) serving to
perpetuate function and endow matter with the vis viva. But how
can such force ever come within the grasp of exact knowledge?
and how can such a force be in any way dependent upon extrinsic
calls for its exercise? Nothing, we allow, would so tend to
demonstrate a prescience and forethought in nature as such a con-
dition. Nor, indeed, could the intangible and wondrous attributes
of the life-force more impress the reflective mind, did we even
credit them with an association of so self-directing a character.
But passing from the general to the special, we see no such mutual
connexion and dependence. We observe that the most densely
Bibliographical A
populated district! are precisely those whose oonditions, hygienic
and moral, might b I antagonistic to life-foi
that the amount of Mich fl lied into existence
atest where no apparent necessity claim- it- e, and wh<
on the contrary, the strongest possible numerical and social i
sent themselves for ita limitation. It is evidence, nevertheL
of a reverential spirit, which dues our author credit, to believe that
tin' amount of force which a given individual can accumulate,
depends on its requirements for the attainment of its ultimatum,
and the proof of such a law would BWOep away many apparent
stacles to the harmony of science and theology.
But the adaptation of the powers for securing the attainment of
the ultimate object held in view at the first moment of being, can
PCely be believed to he modified by conditions and requirement-,
which, of whatever importance to the philanthropist and the stat
man, weigh but little with the master- worker. That the capacity
for repairs under injury exists; that, as in the insect tribes, there
is to be witnessed a power of reproduction, bearing it would
strikingly seem some definite proportion to the waste of life occur-
ring in the offspring, is true ; but it is scarcely legitimate to conclude
— " That under every condition proper to the different epochs of
an animal's life, the formative or productive force is sufficient in
every respect to the necessities of the case."
By the term ultimatum, our author would convey the consumma-
tion of the design in view at the formation of the animal. From
this aspect the ultimatum may be supposed to be attained by the
insect, when it has secured the multiplication of the species in the
form of the necessary number of ova. The ultimatum there being
reproduction, the force in question may properly be styled repro-
ductive; and doubtless in each individual a definite relation can be
traced between such force-manifesting power, and the requirements
of the species. Even here, however, a discrepancy is apparent. It
is, evidently, as much a fixed law that bees should kill each other
en masse, when the queen bee is impregnated, as that they should
lay large numbers of eggs. Is the force then at the creation of the
bee nicely calculated to meet the requirements of a purposeless
waste of it, which is as evidently pre-determined? The inexactness
of Dr. Dobell's conclusion becomes more manifest still, in the case
of man. His ultimatum, evidently, is not attained with the multi-
plication of his species, but only when those duties and functions
have been fulfilled which an intellect entails and enables him to
Dobbll on Germs and Vestiges of Disease. 153
discharge. If the force he proportionate to the ultimatum, it u
evident, here, thai its nature must be bo complex as to remove it
from the scope of pun' reason; :m<l that, Bfl both the duties and
functions of man \aiy in their nature and performance with colla-
teral influences of chance and education, they cannot be derivable
from the force imparted auteeedeutal to them, unless that force be
capable of Leading its possessor to the attainment of an ultimatum
altogether different under different successions of collateral accidents.
To this force, " in one and all of its vitalized modes of manifesta-
tion," Dr. Dobell applies the symbol V.M.F., vitalised mode of
force. If the reader can understand this, he will enter with Dr.
DobeU into the spirit of the " L.M.F.," or " lifeless mode of force."
By modes Dr. Dobell understands what Locke seemed to under-
stand, viz., "such complex ideas as, however compounded, contain
not in them the supposition of subsisting by themselves, but are
considered as dependencies on, or affections of substances." That
is all very well. Of course every one of our readers has sufficient
V.M.F. to enable him to attain this ultimatum. Dr. Dobell is
scarcely to be blamed, for ourselves desponding with respect to the
ultimatum, in an excess of the L.M.F. In the quotation we started
with, we found every one of 63,296 individuals possessed an excess
of V.M.F., to the value of ^. Bearing this in his mind, the reader
may proceed to grapple hopefully with the " succession of transfer-
ences." The " force " is present, but it must (we follow the author,)
be directed in a certain way and accumulated in a definite manner.
The evolution of the radical and first leaves from the seed, is evidence
of an accumulation of force and material from the inorganic world ;
and, as in the vegetable, so in the animal, all are " provided with
the power of accumulating by osmotic action." On this provision
of accumulators depends the transference of force from the food to
the being, and the conversion of simple unorganised to complex
organic principles.
" It may be stated then, as a conclusion from these premises, that
the V.M.F. , in the highest animals, is continually accumulated by
a succession of transferences from the organic world by which they
are surrounded. It is then no more than a postulate" — query
axiom — "to affirm, as I venture to do, that in this manner the
constitution of the animal, both in material and force, will be
dependent on the conditions of the world in which it exists, subject
to alterations correlative with those of that external world itself."
Some of this accumulated force passes by the next step in the
\nd Bibliographical .'■
hypothesis into t! rms of the vitaliied being." The V..M 1
"p :, and "the body having provided for it- decendantt the
r\ to the commencement of their rital
the world at large its residual legafc The Legatee com
this litth' property with mingled feelings; for pari *>t it only admiti
investment, the residue being accumulated for the benefit of
succeeding generations.
By means of this hypothesis Dr. Dobell is enabled to reconcile
the apparently antagonistic operations of generation and development.
In Dr. Carpenter's view these phenomena arc, <>!' necessity, opposed;
for a diminution of the germinal capacity attends r\<vy acl of develop-
ment, while the act of generation renews it. Dr. Dobell, on the
contrary, believes that no loss of vital energy has been sustained
through the budding; but that this extension has been co-equal
with the accumulation of Y.M.F., which has '"been determined in
another direction consistent with the conditions of existence, in
obedience to the law for attaining the ultimatum." Dr. Dobell
does not hesitate to believe that his hypothesis lends dignity to
the law of the conditions of existence of Cuvier, and a new im-
portance to Mr. Darwin's theory of natural selection.
At first sight the connexion between the germ- and vestiges of
disease, and Y.M F., might be thought to be somewhat obscure.
The practical conclusions, therefore, of Dr. Dobell are not without
their value.
" 1. That the vestiges of disease, coetaneous diseases, and the conditions
of life, may determine the efficiency or non-efficiency of the V.M.F., to
prevent or arrest the invasion and progress of premature destructive
changes in the organism, to secure its repair when damaged, to produce
an offspring, to endow that offspring with V.M.F. of normal quantity
and quality.
•• L\ That abnormal conditions of the V.M.F. , either congenital or
acquired, may be changed by changes in the conditions of life, and by
means which exert an influence on the vestiges of disease; and that the
influence of such changes may affect not only the individual but a suc-
ceeding generation."
'o er
We have hinted that, in our opinion, Dr. Dobell can think, but
cannot lucidly express his ideas. His science partakes of the hazy,
the metaphysical, the unpleasing. In like manner Dr. Dobell can
write ; but when he takes to word-painting, his pencil disdains all
attempts at control. The third lecture of our author takes us into the
Dobbll on Germ* and Vestiges of Disease. 155
realms of sweetest tinny and gushing innocence, but the fancy is over-
done, and the innocence smacks of the rouge-pot. It opens like the
scene in Don Giovanni. ZerHna is tripping about in the shortest of
petticoats, and Masetto chirps in the most dulcel of strains. Here
and there the monster of the drama how- hi- w hitc legs, but he does
not forge! his guitar. The V.M.F. enters once or twice and disturbs
the peace of mind of the audience; but lie is in this act BO insinuat-
ing and so gentlemanly, thai we almost forgel what a villain he is,
and how he 18 luait on robbing the girl of her virtue. The synopsis
of this Lecture looks not unlike the exciting and condensed account
of the costly extravaganza of Pretty Prince Pastoral, or Oranges
and Lemons and the Twelve Dancing Princesses. The good
genius of the play asks us to forget the "grim walls," and the
chains, and the beaten paths of our orthodox prison, and gallop
11 across country" in search of medical truth, with an utter disregard,
be it noted, of the selfish interests of all " proprietors of hedges,
fences, and ditches." Whereby hangs a parable.
" You are so perfectly familiar with that road which leads from the
village to the wood, up which you have so often sauntered ; you know
quite well the path to the mill — your favourite evening walk. But I
shall just trot you up the lane at the end, and show you over that thick
hedge on the bank, when you will see that your road to the wood and
your path to the mill run so nearly parallel and so close together, that
the road will take you to the mill, and the path to the wood, by a very
slight turn indeed. I shall take you a gallop to the lake in the valley,
which you always believed had its source in that swampy wood on its
higher bank ; and we shall then climb the hill to your favourite well
under the beech trees, and to the little stream that runs from it, and loses
itself under the rocky side of the mountain ridge. You know these spots
well from childhood ; but I shall take you through the brambles and furze
on the ridge, and down through the quarries on the other side, and show
you your little stream gushing from the rocks again, and tumbling down
the hill-side to the swampy wood. I shall not be stopped by notice-
boards, warning off trespassers, or by your legends of the dangers of the
place. We shall be careful of our footing, however, and perhaps dismount
• and lead our horses slowly through the worst of the stones ; but down we
must go in spite of them, and prove to you that it is your favourite well
under the beeches after all, which makes the wood a swamp, and fills
your fine lake in the valley.
*• I am convinced that you are wrong, notwithstanding the testimony
of your oldest inhabitants, when you tell me that the church on the hill,
to which you have walked every Sunday these twenty years, marks the
Bibliographical A
highest point in the county. It certainly looki from vour village and
from your usual riik-.s as though it might; but come with me acroafl the
eountry, and, screened by those tall treee which appear to -kin the
horizon, 1 will show you a hill almost up to their tops, from which your
church is Been enveloped in the valley mists.
v>w change the scene, and return to life in town. Let as take our
COUr8e across the ups and downs, tin- <piiek--;mds and the thorns, which
beset the study of disease and health. It is still a CrOSS-COUntry route I
wish to take you; hut don't misunderstand me — don't Buppose that I wi-h
you to leave your 'hand-books' behind, or to forget one item of what
you have learnt about the usual ways and by-ways, the well-known
objects of interest, and the public places. No guide is justified in pene-
trating to the interior, till he has learnt all the roads well worn by his
predecessors, so that he may recover the safe track if he finds himself
getting into danger."
The several characters in this chasse an canard are, Patient
number one, who
" Enters while we speak. Be still, and observe his agitated address,
the Hush about the forehead and upper part of his face, the unsteady
- \\ andering about, as though in search of words sufficiently expres-
sive to impress us with the importance of his case.
•• Mark especially the peculiar falter in his speech, by which a syllable
or word is now and again dropped, as though the force from behind
suddenly failed, and the sound went back into the larynx instead of
being uttered."
Then a
" Corpulent flabby old lady, who has a symmetrical patch of psoriasis
on each leg; and is, as she calls it, ' teazed to death with erysipelas of
the ears and sides of the head.' We soon find that instead of erysipelas,
it is eczema ; and in one of her eyes we see an advanced and very yellow
cataract."
Next
" A little child, with large grey languid eyes, and a very white skin."
Who subsequently turns out to be the wrong patient, since it is not
she but her mother who wants advice.
Then the lady herself. She was 30 when she married, and
" Her marriage had been postponed, to suit the wishes of her parents,
that she should wait till her intended husband had attained a certain
position in society, and could bring her a liberal income."
Dobbll of] Germs and Vestiges of Diseasi L57
Next
k* Is a gentleman of <;,), the proprietor of quarries in Wains, and a
director of several companies in London, a very active, energetic man.
I »n t those occupations require tlmt he should frequently travel long
journeys by rail, and be able to sit out protracted board meetings*" &c.
Ladies with quivering lips; short breathed men; children with
the measles; and a retired baker.
Need we observe, that all this leads at last to the transformation
scene, where Prince Pastoral marries the Princess Discretion, in a
blaze of blue fire, pointing with his wand to the " wells and springs
of disease," amidst thunders of applause.
At length, however, Dr. Dobell pulls up his hobby, and drop-
ping his metaphors and his word-paintings, proceeds to work in a
manner more creditable to the thinker and the physician. For,
unless the book aims at the public, we hold that the text we have
just skimmed over is such as it would be flattery to call valueless.
The author's purpose is to insist on the necessity in all cases at
definite periods, of searching for the germs and vestiges of disease.
This necessity, he is desirous to show, springs from the intimate
dependency and mutual connexion of diseases one with the other:
that diseases of serious character frequently are to be traced to
first germs, apparently but trivial in themselves ; and that disease is
acquired and entailed by a non-eradication of the slight vestiges
which, in most cases, after a disease, linger in the system. It is to
the pre-existence of germs and of vestiges, " to this class of changes,
to these vestiges, and vestiges of vestiges, together with the condi-
tions of life, that we have to look for the real causes of mortality in
disease."
A Ye think none the worse of all this, that we knew it all before.
Of course, if a child have the dropsy, a shrewd guess may be given
at the vestiges of scarlet fever. If a young lady is coughing and
thin, a natural inquiry may be hazarded after parental phthisical
germs. If a third have a venous pulse, it would be nothing very
wonderful for a physician to seek for the cause in a remote rheu-
matic fever. But this is not sufficient to recommend the profession
to attend to; the prodromata are scarcely worth writing a book
about, but to caution us against overlooking "the state of the
correlative parts;" and " the quantitative and qualitative state of the
Y.M.F." is altogether a diiferent business. It is not enough that
a practitioner should use his common sense, remembering, what we
Graphical A !
»uld think, no one with common sense could, by an ibility,
<t that produces <li . i but, he must i
keep hii eye upon tin- \'..M F , and the tntial antecedent or
E A;' for the V.M F •• inav be brought to various degrees of
defectiveness," and the F.A. may, **in a certain number of ca
hi- in of any possible condition of the \'..M 1 , either to
protect against the invasion of disease, or to prevent death." Nor
will the etiology of the disease be understood unless he bear in
mind "the essential antecedent — the causes of the essential ante
dent — the pro-disposing antecedents — the causes of these pre-dis-
posing antecedents — the causes of fatality — the causes of these
causes — and the vestige
Passing on to lecture four, we discover the bearing of the princi-
ples laid down in the preceding lectures. We have etiological
analyses of typical diseases, which we hope may prove valuable in
emergencies and at the bed-side. We doubt much, however,
whether the obscurity attending the differential diagnosis of con-
tinued fevers, is in any way lessened by the light afforded by both
the V.M F. and the E.A. The pre-disposing antecedent of typhus
is said by Dr. Dobell, to be a "defect in the V.M.F. compared
with the quantity and quality of the F.A. to which the individual
is exposed." [ts cause, we find, resides in an excess of the FA.
over any possible condition of the V.M.F., while the fatality of the
disease " is most influenced by the volume and intensity of the
E.A. and defective V.M.F." Furnished with these valuable
axioms with respect to continued fevers, Ave may proceed to extend
our knowledge of apoplexy and paralysis, by following Dr. Dobell
into the varieties of the E.A. The wisest may occasionally hesitate,
both as to diagnosis and treatment in these eases. It cannot there-
fore but be productive of the greatest advantage, where there
exists a doubt as to the rigidity of paralysed muscles, or the exist-
ence of a clot, or the presence of white softening, or the epileptiform
nature of a seizure, to bear in mind with our author, that apoplexy
results from an "arrest, permanent or temporary," in one or more
of the functions of some part or parts of the eerebro-spinal system,
caused by a toxic E.A., a mechanical E.A., or a degenerative E.A.
The prophylaxis is further much assisted in an anxious patient,
by observing a defect in his V.M.F. ; and in the event of decease,
it cannot fail to prove of much solace to the relatives, to learn that
the cause of the untoward event was to be ascribed to (A.) excessive
defect in his V.M.F. , compared with the quantity and quality of
Dobell on Germs and Vestiges of Disease. L59
his B.A. or (B.), which 18 "the most usuul cause of fatality in
apoplexy,*' an excessive defect of some part of the organism,
independent of the influence of such defect on the quantity or
quality of the V.M.F.
We dwell, and we regret but briefly, upon the etiological
analysis of heart disease and pericarditis, which arc found to hear
an important and hitherto overlooked analogy to apoplexy and
paralysis, if we may judge by the identity of their respective varieties
of the E.A., which are again ohserved to be toxic, mechanical, and
degenerative. Here again should a patient desire to ward off these
affections, it is essential he remedy the defect in his V.M.F., which
is their predisposing antecedent. To the medical body at large
who are used to consider the causes of fatality in these diseases as
originating in obstructed circulation, dropsy, and such like, it will
be a source of much anxious reflection to know, that they have been
altogether oblivious of the " excessive defect of the V.M.F. com-
pared with the quantity and quality of the essential antecedent,"
concerning the " cause of which cause," it should be remembered,
that " the E.A. may be in excess of any possible condition of the
V.M.F."
In like manner we would commend Dr. Dobell's views upon gout
and rheumatism to the serious notice of Drs. Garrod and Fuller, in
whose works, by an inexplicable oversight, there is not so much as
an allusion to the important dependency of these diseases on the
V.M.F. and the E.A., which, if we consider their fatality, has a
bearing, happily unfrequent, on " the cause of its cause," since " in
very rare cases the E.A. is in excess of any possible condition of
the V.M.F."
This constant antagonism of the V.M.F. and the E.A., to say
nothing of the L.M.F., is very lamentable, and the more so, that
like many other couples at variance, they cling to one another with
a certain fondness which precludes the interference of a third party.
This is the more to be deplored as such a state of tilings cannot
fail to exercise a very depressing influence on therapeutical medicine.
Dr. Dobell is no less entitled to the credit due to having first
called attention to this subject however, than for the industry with
which he has garnered materials for the fifth lecture. TwTenty-two
out of the thirty-seven pages of which this lecture is made up,
testify to Dr. Dobell's thorough freedom from bias, and his modest
appreciation of the text of no less than eighteen authorities, not
forgetting the Times and the Registrar-General. The accumulation
160 liographical A I
of ist . ' trust that for
tin.* future few will be found to deny that syphilis, fatl
ration, and anaemia, are very prolific sources ofd
"Here, Gentlemen, ire find ourselves, at last) near the i that
•iintiv ride, which 1 sketched out in my third lecture. W
lored some of those different roads leading to the same end ; sre have
discovered thai some of those hills that appear to skirt the horizon, may
descend into the mists of the valley when seen from another point of
view. We have traced the lake, the Btream, and the quicksand to iti
ice. In spite of some difficult ascents, some uncertain lootings, ami
many tangled paths, we have at length arrived at those wells and spr
qf disease and death j which we are bo apt to neglect while busy with the
disasters of which alone they have been the eai;
"Gentlemen, we are all members of a practical profession. We have
taken upon ourselves high and responsible duties, all culminating in
action. So long as we choose to assume these duties in a profession, as
yet BO tar from perfection, we are not justified in spending our time in
scientific investigations or speculations, unless they have for their end
some practical application for the good of humanity. It is the hope of
attaining such an end which has led me on in the design and labour of
these lectures.
" I think that such an end, such a practical application of the con-
clusions at which we have arrived, stands out plainly and unmistakably
before us. I hope, Gentlemen, that in your own minds you have antici-
pated me in coming to the same practical conclusion that I have arrived
at myself." ............
" The conclusion at which 1 now arrive is this, that man may be the
instrument through whom the capability of accomplishing these ends may be
ftresi reed and restored to the organism,
" The manner in which man is to exercise this instrumentality is the
next point for our consideration. But I think we have almost reduced it
to a necessary conclusion. For as we have plainly seen that the organism
is competent to take care of itself, provided that it possesses a normal
V.M.F., and is surrounded by normal conditions of life ; and as we have
also seen that the great causes of defect in the V.M.F., are the vestiges of
disease and abnormal conditions of life ; and as we have also learnt that the
diseases, from which the vestiges result, are invited by defects of the
V.M.F. ; and that when thus invited and received into the organism, they
are capable of being disposed of without leaving vestiges behind, if the
V.M.F. is free from excessive defect ; that thus these vestiges are due to
defective V.M.F. And as we have learnt that the earliest invasion of
detects in the V.M.F., upon which all the long and intricate succession of
ills depend as their germ— as we have learnt, I say, that this state of
Ethical Writings of Physicians. J 61
germination exists at a period anterior t<> the manifestation of rlinomic in
its ordinary characters, and that it is to be Pound in the garb of slight
impairments to the genera] health, the indications of which are more and
more evasive and occult, the earlier the StOffi of .'/' nnimiliun ; and, iinally,
as we have learnt thai it is in this occult andeva wt ttag\ of germination that
the defect is most easily and most efficiently to be remedied} I think yon will
agree with me in the practical conclusion ;it which I have arrived." .
"I wish, thru, to propose, as the only means by which to reach the
evil, and obtain the good, that there should be instituted, as a custom, a system
of periodical examination, to which all persons should submit themselves, and to
which they should submit their children." .......
"The examination should be reported in writing ; and, after due con-
sideration, each advice must be given as a careful judgment may dictate,
for the future conduct, pursuits, and habits of the patient, with a view to
correcting any defects, or tendency to defects, in the organism. Advice
must also be given as to the means of removing any vestiges of disease
that have been detected, or if they are not removable, advice as to the
best way of overcoming their influence, or of averting their increase. To
tins must be added precautions to be adopted in certain contingencies,
which, according to the judgment of the case, appear probable."
" The next question is, then, what would be the effect upon the profession
in a pecuniary and in an ethical sense. With regard to the pecuniary
question, it is only necessary to observe that of course I do not expect
that any man in good practice, whose time is profitably employed, could
conduct such an examination and give such advice for the usual consul-
tation-fee. That is, of course, out of the question. Every man who
attempts to follow out the plan, will, I hope, require such a fee as shall
enable him to give the necessary time and consideration to every case."
Have we not proved what we started at first by saying, " that it
is not very easy to avoid doing Dr. Dobell a great injustice; and
that, by taking his words from his own mouth."
Aspirations from the Inner, the Spiritual Life ; aiming to reconcile
Religion, Literature, Science, Art, with Faith, and Hope, and
Love, and Immortality. By Henry M'Cormac, M.D. London:
Longmans. 18G0. Cr. 8vo, pp. 370.
Les MSdecins Moralistes Code Philosophique et religieux, extrait des
Ecrits des Mklecins anciens et modernes notamment des Docteurs
Francois contemporains. Par Madame Woillez. Paris :
Baillike. 1862. 8vo, pp. 399.
It does not come legitimately within our province to notice ethical
VOL. XXXIII., NO. 65, N. S. M
Riviiws and Bibliographical Not\
winks, but those now before us present i peculiar claim t<> our
ntion, not alone from their beauty and excellence, but at beii
the utterances of our professional brethren, the first being from the
eloquent pen of Dr. M'Cormac, of Belfast, and the other a coll
tion of beautiful thoughts, collected by Madame Woillez, from
the writings of our French eonfren
Dr. M'Cormac describes his book, and most truly, ac not ■
sectarian book. It is simply, he says, tlic inculcation of spiritual
truth, a spiritual religion, and a spiritual God; aspirations from the
inner life, the life we do not see, but which, not the less, n ran*
our experience here, and, in a degree, the experience which is to
come. For the earthly is in correspondence with the celestial life,
and the spiritual truths of the present are also true for ever. II«
would raise, or strive to raise, each weary anxious heart straight to
highest heaven. He would unite the beautiful, the elevated, the
good, the pure ; reconcile religion, literature, science, art, nay,
every precious and excellent thing, too much estranged, with
religious trust and religious truth.
Right noble aspirations these, and right faithfully worked out.
The task is one for which the education, the habits of thought, and
the experience of life and death of a physician peculiarly tit him.
The book reminds us of the proverbial philosophy of Tupper, but
is immeasurably superior to it by its profundity, its learning, and
the genial and catholic spirit it breathes.
Madame Woillez is a well-known and highly-esteemed authoress.
Before withdrawing into repose, she was desirous of removing from
the medical body the accusation of Atheism and Materialism, so
often formed against it, and, for this purpose, devoted the last three
years of her life to reading the writings of physicians, " elle parvint,
abeille patiente, a en extraire les sues les plus purs et a composer un
veritable Code Chretien, uniquement du a cette meme classe
d'hommes que Ton pretendait denues de sentiments religieux."
The collection of maxims, thoughts, and reflections, that she has
drawn from the writings of physicians, ancient and modern, — but
chiefly contemporaneous Frenchmen, — makes her book one well
worthy to take its place beside that of our countryman.
TART III.
MEDICAL MISCELLANY.
Reports, Retrospects, and Scientific Intelligence.
RETROSPECT
OF THE PROGRESS OF SURGERY DURING THE LAST DECADE.
BY
MAURICE HENRY COLLIS, M.B., F.R.C.S.I.,
Surgeon to the Meath Hospital and County Dublin Infirmary ; Member
of Council R.C.S.I., and of Council of Surgical Society.
SURGICAL PATHOLOGY.
It is impossible that advances could have been made in physiology, such
as the last ten or twelve years have witnessed, without a proportionate
increase in our knowledge of the principles on which we must combat
disease. I have no wish to encroach upon a province which does not
come within my domain ; yet, their boundaries being conterminous
throughout a great extent, I find it impossible to avoid a reference to
physiology while engaged in the consideration of the present condition
of pathological knowledge.
If I might venture to epitomise the prevailing views of the principles
and forms of life, I would say that, as regards the former, life is now
looked upon less as a combination than as a correlative of the physical
forces, and that the forms of life are deducible from one common type.
Life comes to be recognised, not as electricity or galvanism, not as heat
or chemical action, nor yet as a combination of any two or more of these,
but as a condition of matter (I am not now speaking of the life of the
soul) changeable, under certain circumstances, into any of the other forms
of force, allied to all, identical with none. Ultimately we must refer it,
equally with all other physical forces, to the upholding will of the Creator.
M 2
Pr lery during the ! ■ > I > \de
In the word* ol Groi l Hisation ii the will, creation the w I rod."
The deduction ol the various forms <>f life trom ■ common type fonni the
basis of the theories oi Darwin* and oi 1 reke,' and may l»»- found u
more practical form in almost every page ol l irdi "' Cellular Pathology.
In the 27th page ol this w<.rk, as translated l>v Dr. Cham find the
following exposition ol the doctrine: —
•■ At the present time, neither fibres, nor globules, nor elementary
granules, can be looked upon as histological starting-points. As 1
living elements were conceived to be formed out «»l parts previously
ol shape, M\Ai as formative fluids (plastic matter^ blastema
cytobladema\ any one ol the above views could, of course, be em
tained; but it is in this very particular that the revolution, which the 1
few yean have brought with them, lias been most marked. Even in
pathology ire can now go so far as to establish, as a general principle,
that rw development of any kind begins de novo; and consequently asi
the theory of equivocal (spontaneous) generation just OS much in the hi<t<>r// of
the development of individual parts, as we d<> in that of entire organisms; just
as little as we can now admit that a ta-nia can arise out o! a -aburral
mucous, or that, out of the residue of the decomposition of animal or
table matter, an infusorial animalcule, a fungus, or an alga, can be
formed; equally little are we disposed to concede either in physiological
or pathological histology, that a new cell can build itself up out of any
non-cellular substance. Where a cell arises, there a cell must have
previously existed (omnis cellula a cellula), just as an animal can spring
only from an animal, a plant only from a plant. In this manner,
although there are still a few spots in the body where absolute demon-
stration has not yet been afforded, the principle is, nevertheless, estab-
lished, that in the whole series of living things, whether they be entire
plants, or animal organisms, or essential constituents of the same, an
eternal law of continuous development pre vails. There is no discontinuity
of development, of Buch a kind that a new generation can of itself' give
rise to a new series of developmental forms. No developed tissues can
be traced back either to any large or small element, uidess it be unto a
cell."
In this doctrine of omnia cellula a cellula is contained the germ of the
advances of both sound physiology and pathology.
Virchow has elaborated the doctrine in its multitudinous bearings upon
the healthy and morbid actions of the human body. One by one he has
taken the various constituent elements of the tissues, and has traced them
a Correlation of Physical Forces, by W. R. Grove, Q.C.
b Darwin on the Origin of Species. 1S60.
■ Freke on the Origin of Species. 1861.
I must not be understood as expressing any opinion on these theories. I have merely
referred to them as expressions of prevalent opinions.
Progress of Surgery during the last I>eca<U> 165
up to a common BOnrce— the cells of connective tissue; bone, mnsele,
nerve, skin, tendon, and fat, all own a common parentage; and, as there
will be occasion to show Farther on, aD morbid elements are derived bj
him from the same source.
In this view of the cimunimilv of Origin of cell-elements, theft i- 6
wonderful convergence between independent observers. As regards
physiology, it must be left to others to follow out the subject, while here.
it is endeavoured (<> show its general bearing upon surgical patholo
As life, in its relation to matter, appears Go be a correlative of the
forces of heat, motion, electricity, chemical affinity, &c, so the deviations
from health seem to consisl in the intermixture of one or other of these
force- with the force of life.
Prior to the last decade, the chemical processes of degeneration of tissue
became dimly known to us through the writings of Miiller, Henle,
Goodsir, and Reinhart. To the latter especially are we indebted for the
first outline of the process by which albuminous tissues part with their
vitality, and, becoming amenable to chemical laws, arc converted into oil
(by removal of their nitrogenous element), a prior to their final absorption.
The identity of this decomposition with what occurs in disease was made
out by Quain and Wagner ; but it is especially to Virchow that we are
indebted for thoroughly systematizing the entire range of fatty degenera-
tions. He gives to the changes of which this is the principal, the term
of necrobiosis, which he explains to mean " death, brought on by (altered)
life — a spontaneous wearing out of living parts — the destruction and
annihilation consequent upon life — natural as opposed to violent death
(mortification)."
It is not necessary to follow Virchow through the minutiaB of this
subject ; it is sufficient to point out how, in the typical writings of the
past decade, life is looked upon as a condition, not as an entity; and
disease as a disordered condition.
The all-important signification of these views for the right comprehen-
sion of most morbid processes, and, above all, of the dyscrasice, must be
too evident to require further amplification.
Men are now accustomed to look for the seat of life, not in any one
central organ, whether the distributor of a grosser or of a more subtle
(supposed) fluid, nor in the blood itself, nor yet in the tissues alone ; but
in all parts of the body in proportion to the activity of the changes which
are the evidence of life. As a necessary corollary of this view of life,
we look upon disease, not as a disturbing element, introduced into the
blood or tli Is, but as a disordered condition of structure, sometimes
produced, it may be, by the introduction of morbid material, often without
1 Michaclis (Prager Vierteljahrschrift, 1853) has supplied this missing link, by
showing that ammonia is developed during the oily metamorphosis of albuminous
tissues. Simon in Holmes' System of Surgery.
166 /'/ i I ' ■ / '
aiu-li introduction, but always of more importance than anj inch materia]
rirna; and to be treated by medicinei and means, such ai will enable tic
natural excreta ins to eliminate the «liit«t or disordered tissue, and
not by drugs, which are to act as direct or chemical antidotes I
poison.
Hence, for example, in syphilis, the use of mercury, where it is used ai
all, is modified materially by these news. Men, at least sensible men, <!<>
not nOW deluge their patients with mercury BJ a specific, which is to
circulate through the capillaries, Or enter into the tissues ami annihilai
Syphilitic virus where it meets with it — a doctrine propounded not many
yean ago by some of the ablest teachers in the land; but the\ give it,
even when they rely too exclusively upon its powers as an eliminator of
dead or disordered, or enfeebled tissues. No doubt then' an- terms of
the disease in which it surpasses all other known excitors of the elimi-
nating Organs (such, tor example, as congenital syphilis), but for all that,
it is year by year more universally acknowledged that other means will
cure tin' primary disease, and that mercury cannot insure immunity from
ndaries, no matter how carefully and to what extent it be exhibited :
hence the inevitable conclusion that it is not an antidote in the old sense
of this term ; and so with other diseases and other remedies. As the
former cease to be looked upon as entities, so the latter cease to be
irded as specifics. Such advances in pathology then are not to be
despised, Beeing that they open the way for sound principles of treat-
ment.
A pregnant source of progress in modern surgery (and medicine) is to
be sought in the tendency of men to individualize disease. As the
functions and forms of life are found to present as many aspects as there
are individual men, so are the disordered functions and forms of disease;
families, and groups, and classes, may be made for the convenience of
instruction; but year by year the great truth is more widely recognised,
that diseased action i^ as diverse as man; and the results which spring
from this truth are of immense and wide-spread importance.
Two causes seem principally at work in the production of this view of
disease. The great extent and accuracy of microscopic investigations, and
the increase of medical journalism. As, in many other great changes,
the agents who have brought this about may have been, to a great extent,
unconscious of the tendency and effects of their labours. Thus, some
five years ago, a grand controversy raged in Paris on the subject of
microscopic investigations, and if we were to judge of their value by the
conflicting opinions which were then evoked, or by the absence of any
definite formulae as their recognised result, we should be obliged to
conclude that their contributions to science had been uncertain, and that
their practical importance was of the very smallest amount. And yet
how many errors, and, what is of more importance, how many sources of
Progress of Surgery during the last Decade. 167
error were discovered and got rid of by thia discussion) how firmly it
enabled as to grasp the troth, and to wield it for future use. Many
hasty generalizations many erode and ill-digested speculations — many
theories founded on a too narrow basis, or resulting from incorrectness in
manipulation, were here disposed of, and, when the angry tide, of debate
bad ebbed, men's minds settled down to realize the true results of the
discussion.
The mosl important of these was the infinite variety of morbid growths,
a striking example of the individuality of diseased action. Discoverers
are always apt to generalize too soon and from too narrow premi--
hence the microseopists of the previous decade laid down with too great
rigidity tie- characters of morbid cell-elements; the cancer cell, for
example, was not only characteristic of the growth in which it forms the
principal element, which is true, but it was heteromorphous, foreign to
the body, of parasitic, or at best unknown origin. Each successive
observer of the structure of tumours has pointed out peculiarities un-
noticed before, and perhaps has founded a new species or variety of
growth, insisting mainly, it may be, upon the differences between what
he has seen, and what others have put on record as the results of their
observations. Gradually the varieties are so multiplied that the shades
of difference between them become less and less broadly marked, and
men's minds suddenly open to the conviction that these numerous pecu-
liarities point to a common origin, modified by individual influences.
The expansion of medical journalism is connected also with this
increasing tendency to individualize disease. Whether as cause or effect
may be a matter of opinion. Certainly there is a constant stream of
cases and observations ready to fill the pages of every journal, and each
writer strives for originality, or at least for some peculiarity in the cases
he records.
As before remarked, there is a wonderful convergence of opinion on
the common origin of morbid products. We find independent observers,
who had followed different routes, arrive at the same conclusions.
Virchow, for example, in page 445 of the already quoted work, when
speaking of the origin of pus, says : — " If now, in the next place, we
investigate the history of suppuration, we immediately discover that we
must distinguish two different modes of pus-formation, according, namely,
as the pus proceeds from tissues of the first two kinds mentioned in our
classification, i.e., from epithelium, or from connective tissue." He had
previously spoken of the origin of the former from the latter, so that
ultimately the pus cell would derive its origin from the connective tissue
corpuscle ; further on he shows how — " deeply-seated pus-formation
regularly takes place in the connective tissues. In it there first occurs
an enlargement of the cells, the nuclei divide and for some time multiply
exceedingly," &c, &c.
Progt Surgery during tUn l<tst J'
• in, rpeaking of tubercle, hi laj - ( p. 8 1 ) i — M It the development ol
these corpuscles be investigated, it i i conrince oneself that win
leour they arise out ol pre^ ious organic morphological elements,
I that they are not i>y any tneane the Aral bungling products, oni
tunata inisation; but that Ihey were once well-grown
ments, which, by an unhappy chance, were carls cheeked in their
development, and early Buccnmbed to a process of shrivelling. Yen may
with certainty assume that where you meet with a largish corpusd
this description, a cell had previously existed ; and where you find a -mall
one, there once had been a nucleus enclosed, perhaps, within a CClL
. I am of opinion that tubercle is necessarily of a cellular nature,
and generally, just like all new formations, has its origin in connective
ic"
\ on, oot to be tedious, in p ■ L he has a figure which represents
the development of cancer from connective tissue in carcinoma of the
breast, showing the various stages of the process in the division of the
nuclei, then of the cells, their grouping together and enlargement. He
also assorts similar stages in the development of cancer, cancroid, ami
sarcoma.
Here we see the ablest foreign microscopist and pathologist of the day
deriving the principal morbid products from one common element — the
connective tissue corpuscle. Let us now see how our greatest British
authority treats the same subject : —
"One cannot but conclude that the cells of pus from wounds are un-
developed or degenerate granulation cells. . . . The many characters
of imperfection or <>f degeneracy that pus-cells show accord with this
view; such as the general imperfection of their nuclei; the frequent
abundance of fatty-looking granules in them, the large quantity of fatty
matter that analysis detects in pus, and the limitation of the cells to
certain forms, beyond which they arc ne\ er found developed, though none
of those forms is more highly organised than that of the youngest or most
rudimental granulation-cell. "a
It is strange that one who could speak so plainly of the parentage of
the pus globule should not have perceived the affinity of tubercle and of
cancer to the same elementary cell ; but he goes close to it with Schrceder
Van der Kolk, whom he quotes, as referring pulmonary tubercle to the
degenerate epithelium of the air cells.
Dr. Wilks,1' in a paper on cancer and new growths, expresses his opinion
that these have their origin in a " purposeless effusion of blastema," which
material, in healthy subjects, would become organised for repair or healthy
growth, but in the unhealthy is converted into unnatural forms. He
boldly proclaims both the local origin of cancers and the influence of
* Paget's Lectures on Surgical Pathology, Vol. i., p. 233.
b Guy's Hospital Reports, Vol. iv.
Progre$s of Surgery during the last Decade. l<i!i
the constitution of the indi\ idual, hut in terms too diffuse for quota-
tion.
Ill venture to introduce into mob distinguished company the words
Of one who claims t<» be only a diligent observer of the microscopic
elements of tamonra in oonnexioD with their clinical history, it is because
thev express what, as regards this branch, seems to be t lie result of the
laboun of microscopists in the past decade: —
"Of growths which arc not cancer, but which equally witli it have
their origin in the lymph-cell, and are interstitial or infiltrating, there are
almo-t as many varieties as there are cases. After reading most of what
has been written about them, and having seen a good many, I am satisfied
that this whole class may, for practical purposes, be included in the
following formula: — ' Hie nearer in foi^m and power of development that the
constituent cells of a tumour me to die Jiealthy lymph-cell^ the more innocent is the
tumour: the further removed, the more destructive? Thus we find the healthy
lymph-cell small, circular, slightly granular, with a little nucleus, and
developing into a fibre. Our simplest tumours are composed of cells,
scarcely, if at all, to be distinguished from the above ; and these white
fibrous, or desmoid tumours, are the most innocent possible growths, as a
general rule. A stray exception may occur, now and then, to prove the
rule. We then come to fibroid, fibro-nucleated, recurrent fibroid, fibro-
plastic, fibrinous tumours, named according to the fancy of writers, who
recognise alike their similarity to simple fibrous tumours, and their diver-
gence from them. These are of variable malignancy ; they are of as
variable minute construction. Not only do their constituent cell-elements
differ more or less in form from the primary lymph-cell, but they also
differ in power of development. Some remain always as cells, and never
develop into fibres ; these are the most recurrent. Some make attempts
at development, and hence the caudate cell of various form ; some appear
only as nuclei, without external cell-wall. Again, powrer of develop-
ment into fibrous forms is quite different from active reproduction ;
generally it is not associated in the same cells. The recurrent tumours
are masses of rapidly produced cells, or nuclei, with no attempts at the
formation of fibre.
" Cancer itself can be brought under the above law. It is no heterolo-
gous or parasitic formation. It is simply a monstrously abnormal plastic
growth ; its cells differ as widely as possible from the healthy type. In
acute cases they are rapidly produced, make scarcely an attempt at de-
velopment, and die off with rapidity; in schirrus they are formed more
slowly, and in much smaller numbers, live longer, and make some attempt
at caudation, but they are still further removed in form from the typical
cell of healthy tissues.
" The more I think over the subject of morbid products, the more I am
convinced that, in the above formula, we have the expression of a law
P during the last D
that includes most ol their phenomena. It will, ilightlj modified, apply
not onh i" large classes oi tumours, but alao to tubercle and to pua.
Tubercle ii ■ lymph-cell, ol low vitality, incapable ol development into
healthy fibre, dying after a abort existence, and generally becoming
ign body. Pm may be deecribed in words almoat identical--— their
material difference being one, probably more of chemical constitution than
of vital power — for both are ponaeesed ol aUnoefl a minimum of vitality.
Tumours are compoeed of cells whoee vital force ii >• than pm or
tubercle; and this vital power is rather spent in reproduction than in
development, ai in the healthy cell. The ordinary plastic cell g
through certain phases, dies, and is removed; its place ii taken by a new
cell, developed, probably, from the nucleus of its predeoeasor. The
abnormal Cell tails to arrive at perfection, often la-comes a monstrosity,
and has a tendency not only to reproduce itself from its nucleus, but to
generate, in neighbouring lymph, organisms similar to itself. Thus the
constituent cell of the tumour has a certain independent vitality, similar
to that of the entire tumour; or rather the converse ifl true — the tumour
is composed of cells of independent vitality, and hence it possesses the
same form of life with the cell. And, as the life of the cell is of a low
type, so is that of the tumour. I cannot but think that many of the able
minds which have been engaged in studying cancer, in its minute anatomy.
ha\ e failed to make an adequate impression upon practical Burgery, because
they have been led away to look on cancer as a thing quite different from
any of the ordinary structures of the body, instead of a perverted form of
a natural structure. And I am sure that their views, carried out to their
legitimate conclusion, would lead us to despair of any remedy for cancer
but the knife, or other agents of destruction. Whereas, if we regard the
cancer-cell merely as a perverted lymph-cell, we shall never rest until
remedies are found which will influence it — /. e., the lymph-cell — to a
more healthy type.
" I am sure we neglect too much the auxiliary treatment of good tonic-,
especially mineral tonics, good air, and abundant food, with proportionate
exercise; and we should have slower tumours, and fewer relapses, if we
compelled the attention of our patients to these matters."3
These various extracts indicate a common direction of thought in their
authors, and help to prove the proposition that, the result of pathological
studies during the past decade has been the recognition of a common type
for forms of disease, which had not been clearly recognised before. The
consequences of this recognition must be to simplify much that was obscure
or confused. The entire range of inflammations, whether simple, stru-
mous, or rheumatic, together with all tumours, innocent or destructive,
are shown to have as their point de depart the same cellular element ; and
a On Cystic Disease. By Maurice H. Collis. Dublin Quarterly Journal, Nov., 1860.
Progress of Suryery during the last Decade. 171
however various the immediate change may be which La thus produced
on the typical cells, it Lb not a little remarkable thai the mode <>f their
death La the Bame, whether they have run their course as lymph, pus,
cancer, or tubercle — namely, oily metamorphosis.
The student who would follow out the w hole series of fatty degenerations,
the result of inflammation, will find a clear and simple -tatcmcnt of them
in Mr. Simon's paper on inflammation, in Ilohiu.ss System of Surgery.
Some parts of this essay are so important, as condensations of our present
State of knowledge, that I cannot refrain from quoting them : —
"Let the Btudenl examine inflamed muscle, as for instance, in the post
mortem examination of a compound fracture, or of a recently made stump.
He will find the structure weakened, so that it easily gives way with
pressure or traction ; he will see, under the microscope, that the substance
tends to fall into irregular fragments; that its natural striation is more or
less replaced, first by an almost homogeneous appearance, and afterwards
by an appearance of aggregated granules ; that, with these granules of
albuminous matter, into which the muscle has resolved itself, there is mixed,
even from an early date in the inflammation, a noticeable quantity of oil
drops ; that often these oil drops appear before the disintegration of
muscle has made much progress, and then arrange themselves in such
mutual relation, tran verse or longitudinal, as to suggest that the sarcous
elements have changed themselves, particle by particle, into oil ; that,
little by little, the oil drops multiply to such an extent as to be the chief
visible objects ; the limitary membrane of a fasciculus seeming now to
be almost filled with finely divided oil, diffused through some scanty
connective albuminous material ; that the limitary membrane, within which
the muscular tissue is thus emulsionized, tends also itself to undergo
dissolution, and let its proceeds confuse themselves with the similar
debris of neighbouring fasciculi, till more or less bulk of muscle is
reduced to a state of oleo-albuminous liquidity, and from this point, if
the observer have the opportunity of watching the changes which lead to
convalescence, he will see that gradually the liquified material diminishes
in volume ; that, in proportion as it vanishes, the adjoining parts
adapt themselves to the altered relation ; that eventually only a scar-like
puckering of substance remains to mark the place where muscular
material has irrevocably melted away.
"Let him examine inflamed bone — as for instance, in a carious
vertebra ; he will see that the structure breaks down under his finger,
and offers scarcely any resistance to a knife, that the microscopic texture
is rarified — cancelli, canals, lacunae, being all larger than natural, and the
solid framework all scantier ; that the material is tending to break into
its component parts, and to undergo changes, which admit of its being
removed by the circulation. In many cases, (for example under the
irritant pressure of an aneurisum), he will find that a quantity of bone has
1 7 1 luring i
thus gone, leaying do trace behind — gone, ol course, onrj haying
Brat become liquid ; ami it appear! thai when bom- i^ inflamed, the first
irards this disintegration oonsisti in a breach of th<- ordinary onion
d the mineral and cartilaginous constituents, with a primary
removal of the former ami a ehemioa) change of the latter. If there be
diacharge from the mflamed part, there will be found in it l>it ^ of bo
chemically ami microscopically demonstrable.
•• Let him examine inflamed nerve; he will find the medullary cylinder
of each nerve-tubule falling, a- it were by cross cuts, into Irregular piei
at first large, but as the process advances, getting smaller and rounder
ami assuming the character ol" oil, till at last the tube-membrane is tilled
with oily material which gradually undergoes removal.
"Let him examine the hard texture of an acutely suppurating joint ;
he will find the strongest ligaments in course of being reduced to an
incoherent state — either actually pulpy and hall* liquified and in course of
removal, or ready to break with the least traction; he will find, unless
proper splintage have been used to prevent it, that dislocation it occurring
from this cause ; lie will find, if the inflammation have been primarily
synovial, that the cartilage is smoothly melting away at it- surface, into
the fluid which bathes it ; or if the disease has begun subartieularly, that
the cartilage, where superjacent to carious bone is irregularly eroded and
perforated; and throughout, with the microscope, he will find, wherever
there are evidences of advancing disintegration, that the softening material
is abundantly marked with oil drops."
It would be tedious, in such a retrospect as the present, to go with a
great minuteness into the various modes of fatty or oily degeneration which
affect all morbid cell elements. The principle is the same in all — namely,
that when the life of a cell is over, chemical force takes the place of vital,
and the gradual dissolution of the cell commence-.
I must pass on now to consider how far these sound principles of
pathology, which the last ten years have evoked or continued, have already
borne fruit in practice, and to eliminate what seems to me of permanent
utility from the copious suggestions with which our medical literature
abounds.
SYPHILIS AND GOXOKKIIG. A.
Is Andral's dictum true, that syphilis is so systematic, so symmetrical,
that it may serve as a key to all pathology? Let the following aphorisms,
culled from the works of the last ten years, answer: —
Blennorrhagia and chancre are two affections entirely distinct. — Ricord,
Egan, Acton, Labatt, &c.
The venereal virus produces two principal results — 1, a local inflam-
mation (blennorrhagia); 2, a form of ulceration (chancre). — Vidal de
Cams, after Hunter, &c.
Progress of Surgery during the last Decade. L73
Blennorrhagja if ■ local inflammation, tUcord, Vidal, &c, and never
giyos rise to constitutional syphilis, — Eicord\ Porter,
The matter of a \ indent gonorrhoea may produce abraaiona, and be
followed by mild CBtaneona eruptiona. — Egan, Vldni, Bourne*) Bequm,
A non-indurated chancre ia always a local dianaao, And ia never accom-
panied or followed by aecondarieej the bubo resulting from such a sore, ia
suppurative.
An indurated chancre ia the evidence that the venereal virus has
poisoned ihc >\>lcin. and ha- returned to the sore. The gland resulting
from it ia indurated. — Hicm-d. Acton, Montonier, M < risoniieuve, &c.
A mild form of constitutional symptoms may ensue after a simple
primary (non-indurated) sore. — Egan, Labatt, &c., after Carmichael.
Every form of primary disease may be followed by constitutional
affections, the nature and duration of which no one can predicate. —
//< 'lines Cootc.
Where phagedena is the primary affection, secondary symptoms may
not arise for ten or fifteen years. — Ibid.
The peculiar danger attending indurated chancre arises from its being
obstinate and chronic in its course ; the longer the primary disease
remains, so many more are the chances of constitutional affection from
absorption. — Ibid.
There is no regular interval between the introduction of the poison and
the development of its effects. There is often no attempt at its elimina-
tion, either by the formation of a bubo, or by eruption, or by fever ; there
is nothing periodic or critical in the character of the disease ; it never
wears itself out ; it never recovers or subsides spontaneously ; and though
the virulence of the disease may abate and the symptoms disappear, it
leaves the patient as deeply poisoned himself, and as capable of conveying
the virus to others, as he was before. Finally, one or any number of
attacks of lues, will not protect him from future contamination. — Porter.
It appears to me that the poison, in general, wears itself out, except in
the very severe cases. — Holmes Coote.
Elimination of the poison by the skin is the natural method of cure. —
Weedon Cooke.
A man who has once had an indurated chancre can never have a
second. Inoculation from any source in such a man will only produce
non-indurated sores. — Ricord.
Syphilization is a state of the organism in which it will no longer
evolve the syphilitic virus, in consequence of a state of saturation. —
Ai<:ias de Turenne,
Syphilization is undoubtedly useful against syphilis; it is the only
certain remedy that we know, and it is not pernicious to the organism;
mercury, therefore, ought to be banished as a curative remedy.
Syphilization is not so certainly useful against mercurialized syphilis,
1 7 1 Progress ■ . D
but it ought always to b<- tried; ii often docs cure it entirely, and it at
QOl fail to do lome good in tin -t number .,t cases. —
B eck,
1 believe mercury to in- a specific for syphilis. — Porter,
h is a doubtful question whether mercury is a remedy ;it all
bills. In my opinion it would be wrong to hundredth part <<t
■ grain of mercury to a syphilitic person who had not been bef
mercurialised. — Boeoh
Of 30< • I secondary syphilis, who were treated by sypbilization,
290 were cured. — 1 bid.
The true explanation of cures by sypbilization is the abstinence from
mercurial treatment, and the eliminating power of nature. — Wesdon
Cooke.
A chancre is the only Bource of syphilis. — fficord.
The semen of a diseased man may infect the woman with whom he
may have connexion, even though she never become pregnant. — Porter,
Pus from a primary affection is the only contagious element in the
disease. It may be secreted by the skin, by a lymphatic vessel or gland,
and the ulcer which supplies it may be simple, indurated, or phagedenic.
No secondary or tertiary affection is capable of being communicated by
contagion. — Ricord,
That mucous tubercles may be transmitted is generally acknowledged.
VidaL But mucous tubercles are often a primary affection. — Ricord.
The blood of a patient with secondary syphilis has produced tubercular
and pustular eruptions, when introduced into the Bystem of a healthy
patient by inoculation. — Waller of Prague*
I have great reason to believe that in many of the cases, where a nurse
is said to have contracted syphilis from suckling a syphilitic child, the
disease has been merely thrush. This appears to me partly to have been
;i source of error in Ireland! — Acton,
A woman who has never had a chancre, but who has constitutional
syphilis, may bear a pocky child, who may infect the nur>e. — Porter,
Diday, VidaL, Waller, Ac
A child may be affected in utero, but once born, only by direct conta-
gion ; at least poisoning through the milk of a syphilitic nurse is not
proven. Equally unproved is the contamination of the nurse by a child
which has not primary sores. — Ricord.
Many more opposing aphorisms might be accumulated, if necessary,
for my purpose. This is to point out how impossible it is to dogmatize
on the subject of syphilis in the present advanced state of pathological
knowledge, without meeting with an opposing truth, no matter in what
direction our prejudices or imperfect observations may lead us.
Varieties of Primary Syphilitic Sores. — The opinions of Ricord, Porter,
Lee, Weedon Cooke, and many others, all tend to recognise the individual
Progreu of Surgery during t/>e last Decade. 175
as the modifying agent <>t* the poison; and sucli must manifestly be the
truth. Dissecting wounds affect the system or not, acoording to the
state of health of the individual) and Byphilis baa much in common with
them. The sanguineous man will develop an active inflammation, with
.1 tendency to soft chancre and suppurating bubo; the man of languid
circulation, ou the other hand, has a tendency t'» chronic induration, both
local and glandular. The Vfhiskey drinker is notoriously subject to
phagedena, whether ulcerative or gangrenous. Each, according to his
natural temperament, or temporary condition, has power to modify a
poison which, of itself, has been modiiied by the source from which it
was derived.
It is manifest that contagious disorders acquire virulence of action by
concentration and rapidity of circulation. An epidemic is modified by a
hundred circumstances; and syphilis, as any other contagion, is equally
subject to continual alterations. It is no mathematical quantity of
(invariable value, but an ever fluctuating power which it requires much
calculation to determine. Like all other diseases, it is not an entity but
a condition, and the minds of men should no longer be diverted from the
due recognition of this fact, by the circumstances of the system coming
under its influence through the operation of a virus.
Its modes of action are reduced by Lee to four, namely, — Adhesive,
Suppurative, Ulcerative inflammation, and Mortification, the first only
being followed by constitutional symptoms, and requiring mercury. His
views are given at length in Holme's System of Surgery, to which we
must refer our readers.
Of Improvements in Treatment. — The principal is the reintroduction of
mercurial fumigation, long since recommended by the late Mr. Colles,
whose cinnabar candle was well known to us as students. Mr. Langston
Parkera has been the steady supporter of this plan of treatment for
upwards of twenty years. It is now in very general use in London ;
combined with the vapour bath, it is an admirable mode of bringing the
system under the influence of the medicine. Syme holds that the
mineral should be used only as an alterative and absorbent, in which
view he is followed by most people, only that some hold that it may be
pushed until it touches the gums without interfering with this mode of
action.
For my own part, I would use it for syphilis as for any other
complaint, regulating the amount and frequency of the dose according to
the circumstances of each case, and, as Mr. Porter used to say, according
to the apparent strength of the patient.
Inoculation, — On the subject of treatment by inoculation, many of the
contradictory statements and many fallacies are got rid of, if Mi*. Porter's
a Reviewed in our August Number.
/'/- ■ I' "le.
law be Anything like universally true — that the poison will not return on
itself. As a means of euro, inoculation is acknowledged t«. be uncertain,
icck, whose statements go no further than to show that ai
its use the dis< led to manifest itself externally. Jl should
have the i power to propagate healthy children idd
admit that a ours was proved* Syphilization, as a means of cure m
however, be allowed to die a natural death; ami ;l- a means of dia
Air. Porter's law shows it t<> be of no practical value, for in doubtful
m no ..in- would try the question by syphilizing what EUeord call- s
virgin subject. No doubt, laws arc not absolute, being, alter all, only
the expression of the experience of one or more men on certain points,
but they air at negative value.
In the physiological history of inoculation, Bicord has developed many
points of practical interest, BUCh as that the period of incubation is in
proportion to the depth to which the poison penetrates, and that for the
production of a chancre, an abrasion is necessary. This is, however,
denieti by Labatt. Kicord also points out that chancres only poison
while p ogressing as chancres, or at least when not healing. We musj
caution the readers of his letters against confounding his vfcui dtVQtum
with our elevated ulcer; the former being an ulcer with raised edges, the
latter with elevated ^Ungating surface.
For Tertiarita, an addition to our treatment is given by Gamberini,
of Bologna, in the form of iodide of sodium, the advantages of which are
stated to be, that it is better borne by the stomach, and has a more
agreeable taste ; that it has for its basis a salt which is a normal
constituent of the body, to a large extent, and that it produces Less
iodism. We can here only refer to the interesting remarks of the
same author, on the truces of syphilis, in the 17th volume of this
Journal.
Gonorrhoea, — The treatment of this affection has varied little in the
past decade. The local nature which is all but universally ascribed to it,
has led more men to treat it by simple local astringents. It gradually
passes back along the urethra, and if it can be cut short before it reaches
the sinus pocularis, epididymitis will not come on. Dr. T. Chambers*
believes even that it will get well spontaneously, from two to three
weeks, if let alone. It may be observed, that in all inflammations, local
remedies must be applied weak and often while the action is acute;
strong and seldom when it is chronic. This should be followed out in
gonorrhoea : two grain solutions of alum to be used every half hour in
acute cases, and in chronic, a drachm or two to the eight ounces — used
twice or three times a day. In the intermediate stages, intermediate
strength and frequency of injections, in an inverse ratio, should be
adopted.
a Lancet, June, 1861.
Progreu of Surgery during the last Decade* 177
So in gonnrrlhnil ophthalmia* a half gnill solution of nil rate of silver
;i])|)lic(l every half hour will almost invariably caf short the disease in 24
hours. Carefully carried oul it will scarcely ever faiL
The following l;iw is capable of wide application, both bo inflammations,
internal and external, and for llic exhibition of m.-iny medicines. The
■ton unit, th< diseased action, the weaker ami th, men frequently applied should
our remedy he; th more chrome the action^ the stronger <md lees frequently
applied. In reoommending injections as sufficient to cure gonorrhoea, it is
not intended to exclude the use of such genera] treatment as may seem
necessary, such ;i> purgatives, antispasmodics, tonic.-, &C., but the use
of the nauseous and disgusting eubebs, copaiva, or terebmthinates, may
be altogether dispensed with.
Mr. Weedon Cooke, Mr. Borlase Childs, and Mr. Warner" corroborate the
value of injections above all other treatment. Their favourite astringents
are the chloride of zinc, perchloride of iron, and solution of the pernitrate
of mercury ; more especially the last, at the strength of half a minim to
the ounce of water. Cures are said to have been effected by the last after
six injections, and the disease seldom exceeds 10 days in duration.
MM. Caby and Moulsonb speak highly of bismuth as an injection. The
bismuth to be well washed ; and 20 parts are to be mixed with 200 of
distilled water.
In gleet , Adams recommends the use of five grain doses of Chian tur-
pentine, its action being upon the follicles and ducts of the prostate.
Muriate tincture of iron and tincture of opium will often render the
discharge in such cases somewhat purulent, when injections will effect a
cure.
DISEASES OF BONES AND JOINTS.
What is new and proven on this subject is well condensed in Mr.
Bar well's book.0 The views of Virchow on the nature of inflammation,
as a hypersecretion in the first instance, are supported.
Synovitis is shown to be from the first accompanied by increased mois-
ture. Dr. Fuller, following Todd, attributed the rheumatic tendencies of
fibrous tissues to a peculiar attraction which he supposes them to possess
for lactic or lithic acid ; but seeing that the decomposition of these very
tissues will produce lactic acid, it is more reasonable to attribute the
presence of the acid in the blood and in the tissues to such decomposition,
and not the decomposition to the presence of the acid ; such is Harwell's
view.
Cartilage. — Brodie's ancient theory, that the cartilages are the seat of
active vascular inflammation, has gradually been subverted; first by
* Lancet, Oct. 12, 1861.
b Medical Times and Gazette, June, 1861.
e Barwell on Diseases of Joints.
VOL. XXXIII., NO. 65, N. S. N
/'/ luring ! I / '
\ E then by Richet, Ecker, Goodsir, Redfero, Birkett, an<i
B int. The reaction oi opinion, as usual, h and all
changes in cartilage were ascribed to atrophy, in oonsequt the
proved absence of all vessels in its Btrnctnre. The proliferation <
tilage celli from inflammation, lui<l down by Yiivhov. limed I
discovery by Harwell; probably both arrived at the same conclusion by
independent reasoning. He shows, with Virchow, that ulceration
cartilage depends npon nitty degeneration, and that true inflammation oi
cartilage consists in a hypersecretion of the cells; he denies that the
latter occurs as ;i primary affection; it is for him always a result 1 4
synovitis or osteitis, but it is no less an active process, partaking of the
nature of inflammation in other structures, in that it is characterized by
increased activity of production.
Osteitis. — Mr. Erichsen has done good service by drawing attention to
the fact, that in disease of the tarsus the bones art' primarily affected, the
joints remaining tree until a later period. Osteitis, and not synovitis, is
to be combated: hence, as he advises, excision of the individual bone or
bones should be done. I have found free incision into the body of the
bone equally useful in some cases ; these bones are peculiarly liable to
congestion, which runs on, if unchecked, into suppuration and caries ; they
rarely become necrosed, and a free and timely opening may cut short the
process of destruction. Mr. Harwell has pointed out a similar fact as
regards the articular ends of long bones in children, which accounts for
the readiness with which joint inflammations light up in early life. The
growth of the bone takes place mainly, as is well known, at the epiphy-
sary junction: hence, there is a permanent and normal hvperaniic con-
dition of the bones at this point as long as active growth is advancing,
and it needs but some trilling cause to increase hyperemia to congestion,
and when congestion takes place, either active inflammation may quickly
come on, or a low state of nutrition be induced, which will run into
strumous osteitis, and the whole train of chronic disorganization of the
joint. Klose'1 and Chassaignaeb describe as something new that formidable
inflammation of the shaft and ends of the large bones which we haw-
long known in this country as complete acute necrosis, where the entire
thickness of the bone perishes suddenly from inflammation, frequently
destroying the life of the patient, as well as his limb. Klose had seen the
disease in the young in whom it is more common, for the reason already
given ; Chassaignac had seen it in older patients ; Gosselin points out
their identity, and names it acute suppurative epiphysary osteitis.
Instances of the disease have fallen under my own notice in the shoulder
and in the knee, destroying the limb, and ultimately the life in the latter
* Prager, Vierteljahrschrift, Jan., 1S60. Epiphysentrennung or Meningo-Osteo-
Phlebitis.
b Monograph sut L'Osteo-myelitis.
Prot/retts of Sunjrn/ during the laet Decade. 179
case, and only stayed in the former by \<tv live incisions down
to and along the bone; <»n a small seals we see ii in paronychia
osaeoaa of the nail-phalanx, or bone-felon aa ii i- termed by the Ameri-
cans.
Mortou cocoa, —Bust, of Vienna, aM arte thai osteitis is the invariable
starting point of hip disease. No doubt this is true of chronic morbus
oozes, whether strumous or rheumatic, but the acute disease is clearly
synovitis ; the great width, depth, and fulness of the gluteal region, the
■welling and tenderness in the groin, and behind the trochanter, the
marked increase of heat, great pain on motion, and, above all, the \eiy
rapid destruction of the joint, all prove that t he synovial membrane and
softer tissues are primarily engaged.
Mr. Bmylyhas drawn attention to the fixity of the joint in the early
Stage of chronic disease, as evidenced by rotation of the entire pelvis
taking place on the sound joint when the affected limb is grasped and
rotated ; as a means of diagnosis, in doubtful cases, this manoeuvre is
positively invaluable.
The rarity of dislocation on the dorsum of the ilium is recognised by
all writers, upon the subject of hip disease, in the last decade — the
symptoms supposed to be characteristic of it being attributable to
absorption of the head and neck of the os femoris, and to expansion of the
acetabulum. Tessier,a of Lyons, asserts that prolonged immobility of a
joint may not only aggravate existing disease, but produce various lesions in
a joint previously healthy, so that five or six months' perfect rest sufficed to
destroy the synovial membrane and cartilages. Hiltonb in delivering his
admirable lectures on pain, gave a striking contradiction to this state-
ment, by exhibiting the cramped and unused foot of a Chinese lady, in
which the articular surfaces had remained uninjured under the strongest
possible pressure and the most absolute immobility.
Treatment. — A combination of nitrate of potash and antimony is
recommended for acute synovitis in strumous patients, in place of
mercury, by Barwell. In the use of leeches lowering the patient should
be guarded against, for unquestionably suppuration follows their use when
pushed too far. In fact, in any case of acute inflammation such a result
may occur, and if it be wished to favour the formation of matter, it can
often be done by grouping a few leeches over the spot where this result
would be advisable.
In addition to the chlorides for purulent infection and deposits in joints,
the hyposulphites have been vaunted. Paoli recommends the sulphites
either injected into the veins or internally administered in cases of this
kind, and in all diseases arising from an animal ferment — but this has yet
to be tested.
* Coulson in Lancet, April, 1854, and Braithwaite, Vol. 30.
b Published in Lancet, November, lbtU.
n2-
Proart i i ' i,-
The advantages oi free incision into joint* which are lull oi pus tad
shreds ol cartilage, were laid down, ju-t ken ye bj Mi G
showed the inadequacy ol sinuses for free discharge <>i these prodn
lestruction, and pointed out the reparatiTe power ol joints when fin
from their pr< In this he was seconded l>y A damn ol London,
Brodie, and now by Barwell Snbcntaneoni lection in hydrarthn
practised by Goyrand, Beeins to bare met few followers; nor ha
Velpean and Bonnet's injections ol iodine. Borne good i I the latter
are given by Dr. jjCDonnell ol Montreal,* but we havejaot found reason
to use it in Dublin; as linn pressure, with cold or stimulating Lotions,
generally reduces the swelling to reasonable dimensions, and Scott's stimu-
lating strapping docs the rest.
For chronic synovitis, as well as for the more medical ailments of
rheumatic gout, the Turkish bath is of essential service, as are also the
various modifications ol hoi air and vapour baths.
As remedies for the pain in strumous joints, Jobert de Lamballe
recommends an ointment ol from one to three drachms ol nitrate ol sflvOT
to the ounce ol lard. This acts as tartar emetic ointment does, by pro-
ducing an eethymatous eruption. Veratrine ointment is recommended by
Klinger/" The actual cautery is highly praised by Syme, and recom-
mended with all the persistence and energy of that able surgeon. Barwell
speaks disappointedly of it. The danger is, undoubtedly, lest it should
become an irritant Instead of a counter-irritant. Lebert speaks highly of
the douche, in the later stages of cure, as a stimulant to absorption of
plastic deposits. Coulson advises it for hypenemic and congested condition
of the epiphyses.
Solly places the greatest confidence in repeated issues in strumous
joints, and states that he has almost invariably succeeded in obtaining
either anchylosis or a useful joint by patient perseverance; as a proof ol
which, he has been called on to amputate for white swelling but twice
during his long career as a surgeon.
Chronic Rheumatic Arthritis. — The writings of Robert Adams and R.
W. Smith on chronic rheumatic arthritis have been so long before the
profession, and are so well known, and highly appreciated, that we have
not thought it necessary to refer to them on the present occasion. The
splendid monograph of the former surgeon has exhausted the subject.
EXCISIONS OF JOINTS.
" Removal of a joint may be called for to save life in the height of an
acute disease, to cut short the wearing process of a chronic and incurable
* Paper read before the Medical Society of London— Med. T. & G.. Vol. 24.
b Montreal Medical Circular, 1857.
c Dublin Hospital Gazette, February, 1854.
Progress of Surgery during the last Decade 181
disease ; to rid the patienl of i deformity and encumbrance.**1 In deciding
on operation, and mutatis mutandis^ in making the choice between excision
and amputation, "the most essentia] questions are: — Is the patient's con-
stitution capable of ultimately conquering or healing the disease? It' so,
a\* i 1 1 the limb be of value or an encumbrance? In his worldly circum-
stances i> it possible for him to await a long, and. perhaps, a doubtful
process »>t" cure r"
N<»w, in the first place, as regards acute destruction of joint-, as a rule
free incisions will save as the Qecessityof either excision or amputation.
Where they will not do so it is because the cases run into the category of
chronic disease.
As regards chronic disease, the rule will be different for the child and
for the adult. Children have great powers of recovery, both local and
constitutional. Many a condemned limb has and can be saved by
patience. If operation be clearly necessary, it must be remembered that
after either excision or amputation in the child, the remains of the limb
are dwarfed and withered as compared with the sound limb. This point
is set at rest by Pembertonb and Symec as regards excision. A writer in
the Lancet* states that it is equally true as regards amputation, and
Mr. Humphry's paper in the Medico Clrirurgical Transactions for 1861,
explains the reason. He finds that the growth of a long bone takes
place at its epiphysial lines, generally, with unequal energy; and that
the growth is greater at the end where the epiphysis is last to unite,
which is generally the larger end. He finds, also, that the growth of a
stump is not usually proportionate to the rest of the body, and is least so,
when the more quickly growing end of the bone has been removed.
Yet we cannot accept as sufficiently conclusive the statements of Messrs.
Humphry, Price, and Butcher, that, by confining our resection to a
portion of the epiphysis, we shall not interfere with the growth of the
limb. For Mr. Syme's experience disproves the statement.
Again, it is impossible to know beforehand how much bone may have
to be removed. When a thin slice is cut off, another and another
may be found necessary, until it is cut far beyond the epiphysial
junction.
If the statistics we have be full and honest, their result is, that, as
regards life, excision is, for all joints, a more favourable operation than
amputation ; but it is greatly to be feared that many of the unfavourable
cases have not seemed to those who have had them to present sufficient
points of interest for publication. For diseases of the ankle, elbow, and
shoulder, excision is now confessedly to be preferred to amputation. As
to the wrist) knee, and hip, the fullest attainable information is necessary
■ Barwell, op. cit. b Br. Med. Jour., 1859.
c Pr. of Surgery. d Jan. 14, 1854.
Pt ■ /'
for the formation of any decided opinion. II : lder,a in hi^ admirable
and Uborious work on resections, rorj lull statistical tables on the
ect, up to the latest data.
Wiif.— -The remit* here are ai follows: — Tola] refection of radius,
ulna, ami carpal bom-, li known .■ . i death, 9 Bucceeafol results,
9 partially so; of partial resections, 85 known 8 deaths, 2t> successful
results. The oases of this excision are bo few that it i> not adi isable to m
parate table of those operated <>n in the past decade. It may, howei
be remarked that most of the total resections come within that period.
A • u-.U excision of the wrist joint for caries, there is ■ tendency to
relapse and ultimate failure, which, from the nature of tl
unavoidable. Both the number of the small joints and the multitude of
tendinous sheaths, which must necessarily be opened, predispose to
burrowing suppuration. The tendons and their sheaths may be avoided
by making the incisions longitudinal, hut the operation, in such case, will
be troublesome and tedious, and if the disease is extensive, these incisions
will not suffice. "When such operators as Fergusson, Simon, &c., hi
to put on record repeated and unsuccessful operations, and when, to come
nearer home, Mr. Butcher, who has so distinguished himself as the
champion of excision, is obliged to he satisfied with fingers permanently
flexed, as the best result of his well-planned operations, it can only be
concluded that the operation is of exceptional application, and of more
than doubtful result. Where it is not possible to execute it by longitu-
dinal incisions, Mr. Butcher's modification of the transverse incision, by
which the muscles of the thumb and their tendons are spared, is of great
value, as assisting in retaining a useful amount of motion in the thumb.
Knee. — Of total resections of the knee, 183 oases an' collected by Hey-
felder, from Filkin's first case, in 1762, to the end of 1859. In the last
ten years there have been L46 known cases, 87 deaths, 17 secondary
amputations (of which number all but one recovered).
The results as regards use of the limb are —
1 with limb bowed at the knee.
1 fihfOUS union only.
4 condition unknown.
10 still under treatment, progressing favourably.
76 result given as good in various degrei
Pyaemiaand tuberculosis were the chief causes of death.
The results, then, are 1 death in 4, or 26 per cent.
From these numbers let us now deduct all who were operated on under
the age of 15.
There were 38 such cases, the particulars of which were more or less
known.
* Operationslehre und Statistik der Kesectionen. Von Dr. Oskar Heyfelder.
Vienna, 1861. Reviewed in the last number of the Journal.
Progt\ > ry during the last Decade. L83
Five of these died, and four were subjected to amputation. In one
instance an inf ant of two years of age was subjected i<> this operation 1
it died.
Comparing the statistics of the operation daring the pasl ten yean with
(hose of the previous period, from 1 7 < "> i^ t<» L8j)l, there appears a decrease
of ."»!) percent, in the rate of mortality. One-half of those operated on
died in the early period. Jones' operation in L851 marks a new era.
Heyfelder's tables are not absolutely complete, bul they arc the best
available at present) and probably give as true an account as can be
expected from statistics.
There an- a few cases of partial resection of the knee joint, but they
present no mat* rial feature. As regards the mode of operation, Mr.
Butcher's papers on the subject in this Journal, leave little to be added.
He prefers the II incision, and now recommends the removal of the
patella. Hutchinson suggests to divide the ham-string muscles, in order
to check the forward tendency of the femur. Few cases will require
this, as, by attention to Mr. Butcher's suggestions, especially the
adaptation of an anterior splint, this source of annoyance will be
obviated. Another suggestion of Mr. Hutchinson's may deserve more
consideration, namely, the making of a button-hole opening in the ham,
in order to prevent lodgment of pus in the deeper parts of the wound.
This gravitation of matter is a fertile source of disappointment — infiltration
of the areolar tissue and diffused abscess, with destruction of the
periosteum and extension of the osteitis — consequences which such an
opening might help to prevent.
As to the selection of cases for excision, where operation is indicated,
it has already been said that free incisions are the rule for acute
suppurative destruction of the joints. Coulson denies the frequency of
strumous disease of joints ; if this be true, much more may be done by
patience on all hands to avoid operation than has hitherto been effected,
especially in children. No joint should be excised when there is reason
to suspect purulent infiltration of the cancellated tissue of the bone to
any extent. These cases are characterized by tenderness along the bone,
by the ramification of blue veins over the joint, by a transparency and
glossiness of the skin in the same situation ; by gnawing pains, and a
sensation sometimes as if the bone would break ; by great want of power
to use or bear upon the limb, and by a comparative absence or rarity of
sinuses. Such cases are much better suited for amputation than excision,
and unfortunately they are of frequent occurrence.
The model case for excision is the white swelling, which will not
anchylose, or which, from receiving a hurt, is running on to a suppurative
condition and threatening the life of the patient. There is a condition
more frequently found in the wrist and elbow than in the larger joints,
viz.. where the disease is limited by a cup of plastic material, that
I > I /'< ' ' / '
imes ossified and imparl inflation "t in< thickness Hid
hardness, without tenderness; this condition, in 1 1 1 * - rast majority
v\ ill surely get well by anchylosis, partial <<r complete; but
•liillv tin- patient's strength threatens t-. give iray, and excision n
called for; it is a rare it the most promising for the operation,
l h museums are without old specimens «>t bones amputated for Rich a
condition of things.
I nun up in tlu- words t»t' Mr. Barwell — words which, though bearing
evidence <»t very hasty composition, inculcate sound practice, — "The
operation must he considered as still subjudice. It has zealous advocacy,
and hitter antagonism. At the present time the balance of evidence
DOS rather in its favour, hut we have not all the evidence. It cannot
be said either that preference should hi' given to excision or to ampu-
tation; hut, it mav be observed, that the choice of cases for excision of
the knee, should he very carefully made, and that it is n<>t an operation
which can he practised in an equal number of diseases of that joint, as
vtion of the elbow or shoulder, in maladies of those articulations."
Hip joint and head of femur.— As regards excision of the hip joint and
resection of the head of the femur, the most complete statistics are to be
obtained by a comparison of Heyfelder the younger's monograph, and a
paper by Fock, in Langeribeckfs Archives. By collating their tables for the
years 1851 — CO, inclusive, the following results are arrived at.
Seven cases were operated on for gunshot wounds, of which but one
recovered;11 but seeing that amputation for gunshot wounds of the hip
joint may he said to be invariably fatal (but one exception is on record),
and that all patients who are not subjected to operation also die, this
ratio of success is sufficient to justify the adoption of excision in such case9.
Omitting cases of which we have no recorded result as to the life of
the patient, it appears that in 08 instances excision of the hip joint has
been performed for disease, during the decade. Twenty-seven of th
patients died in periods varying from a few hours to 18 months after
operation ; one died of phthisis after three years. Of the remaining 40,
26 have limbs of varying degrees of usefulness, live are still on crutch. ts,
two are still unhealed, and of seven, the result, as regards the limb, is not
known.
These results are not cheering, but they are quite sufficient to induce
us to operate, if death seems otherwise certain, and that the circumstances
of the case hold out any prospect of Buccess. Resection of the head of
the femur stands on a different footing from other resections in the extre-
mities, inasmuch as we have no practical choice between it and ampu-
tation. The latter is not applicable for disease of this joint, and has been
* This case was operated on by Surgeon O'Leary in the Crimea ; Staff Assistant-
Surgeon F. O'Dell, who was present and assisted at the operation, states that this man
subsequently had a very useful limb.
Progress of Surgery (luring the fust. Decade. 185
invariably fatal when attempted. I m<1« «'«1 no modem Burgeon ifl likely to
risk his reputation by repeating the operation: hence, we are justified in
resorting to resection, if we have any reasonable probability of sued
Mr. Hancock" has shown thai the more formidable operation of excision
of tin1 entire joint, is capable of s favourable issue, at least for a time.
In three of the successful cases given in the tables of Pock and Heyfelder,
perforation of the acetabulum and infra-pelvic abscess are mentioned as
complications.
Ankle. — Excision of the ankle joint is satisfactory in its results. In
the hands Of Mr. Hancock, the deaths have been not greater than one in
four, and the iimbfl have been very useful, even in patients who have to
earn their hread. In Heyfelder's tables but two deaths are noted in 22
cases, and two secondary amputations; nearly all the cases are reported
as useful joints with motion, but two being anchylosed. Excision of the
os cahis and of the astragalus may also be looked upon as proved and
found useful in suitable cases. Nature supplies a large amount of firm
fibrous tissue in the room of these cancellated bones, and in the case of
the os calcis, a high heel of cork or wire-spring supplies any remaining
deficiency. In our present number we have an interesting account of two
new cases of resection of the astragalus by Dr. Heyfelder.
Scapula. — Complete resection of the scapula has been done four times,
by Langenbeck, Syme, Heyfelder, sen., and Jones. The cases of the
first three died, the other convalesced; of partial amputations, to any
extent, seven out of 15 died.
Maxillary bones. — Heyfelder, sen., has four times removed both superior
maxillary bones. Three of these are detailed in our 23rd volume, the
fourth in his son's monograph.
The first, a case of cancer, survived the operation 15 months, dying of
a return of the disease.
The second, a similar case, died in rather less than two years after the
operation, of a return of the cancer.
The third had survived 14 months without any sign of return of disease
at the last account. This operation was done for what we should call a
lupoid ulceration, but there is no proper description of the nature of the
morbid mass.
The fourth case died 40 hours after the operation, having disease of
lungs, liver, and kidneys. Other operators have performed the formidable
feat of removing these bones, — Dieffenbach, Maisonneuve, twice, Dietz,
Jungken, and Langenbeck.
Four cases out of 10 may be considered successful ; in one the result
is not known.
Direct Injury. — Excision is of great value in cases of direct injury. It
■ Lancet, 1857-8.
Proor * the last I)
i-, well known that tae rate <-t death, after amputation, ia high in mch
iii.l especially in gunshot wounds; tin- result! oi the Crini
i. rally in favour ol tin* attempt to save the limb by
ision of the shattered joint where practicable; the mortality is hi
hut not higher than that of amputation. Guthrie long since laid down
the rule — in gunshot wounds *»t' the bead of the humerus and of the elbow
joint - to lave tin* limb by excision, even it a large piece of the shaft has
lobe removed in the former case; and this is perfectly in accordance
with the results of more recent experience. An excellent example of the
application of this operation in a case of compound fracture of the elbow
joint, lately occurred in the practice of Mr. G. II. Porter; the limb i
not only preserved, but was eminently useful for the purposes of the
man's trade as a painter.*
Anchylosed Joints. — The question of forced rupture of anchylosis, raised
by Stromeyer, Louvrier, Dieffenbach, and Langenbeck, is considered by
11 Imes Coote,b Barwell»c Brodhurst,* TampluV Hingston,' Frank,1 and
other-.
It will be remembered that Stromeyer advocated gradual extension, or
flexion, alter subcutaneous tenotomy, that Louvrier and Dieffenbach
forcibly and suddenly ruptured the anchylosis, and that Langenbeck
followed in their steps, discarding, perhaps, the extreme violence which
led to rupture of vessels and nerves, and to fatal injury to limb and life
in the hands of Louvrier. Langenbeck uses considerable force, under
chloroform, but does not insist on completely restoring the mobility of the
joint at the first seance. The result of his practice, according to Mr.
Frank of Manchester, has been so eminently successful, that, out of 150
368, he has only lost one, and that by what he terms central necrosis,
extending through the epiphysis, and communicating with the joint.
Mr. BrodhuTSt seems to break lip the adhesion by a succession of slight
jerks — a plan admirably adapted for getting rid of fibrous bands of small
size, which not unfrequently form the sole obstacle to moderate use of the
joint. lie replaces the limb in its position of anchylosis for a few days,
until inflammatory reaction subsides.
Mr. Barwell urges the propriety of early passive motion during the
process of cure, so as to prevent fixity.
The subcutaneous section of tendon and muscle, even to a considerable
extent, is advocated by the same writer.
• Dublin Quarterly Journal, Vol. xxx.
b British Medical Journal, September, 1858.
• Op. Cit.
d Medico-Chirurgical Transactions, Vol. xl.
e On Deformities, Medical Times and Gazette, 1858.
f Glasgow Medical Journal, July, 1853.
' Medical Times and Gazette, August and November, 1853.
Progress of Surgery during the. last Decade* 187
AMI'I I \ I IONS.
Mode of Operating. — On tin* subject of amputations, we hare a principle
laid down by Mr. Lane, in the new edition <»t Cooper's Surgical Dictionary,
which is t<> guide as in the selection of the flap or the circular method.
Slightly modified it stands thus. When amputation is required for
accident in ;i limb no1 gorged by inflammatory exudations, the circular
method is to be preferred; but when the plastic effusions of rectal or
chronic biflammations hare glued the skin and muscles into a firm and
tmretracting mass, the double flap will be found 1><>th easier <»t' execution
and more satisfactory in its results. Of Teale's rectangular flap we liavc,
as 3 at, too limited experience ; it would appear to be best suited, in cases
of the former class, where lacerations from machinery or other causes
interfere with the circular method.
Ani])ufalloiis through the Condyles. — These begin to be looked upon with
disfavour, notwithstanding the approval of them by Syme and Ferguson.
The cancellated osseous tissue abounds so with veins, that phlebitis of a
dangerous character too frequently results from it. Probably amputations
at the joints, or in the contiguity, as the French term it, will succeed
them, and deservedly so, in suitable cases. The cases which demand
amputation at the joint are, however, but rare, and will be limited, as a
rule, to the upper classes, as the stumps obtained from amputation in the
continuity are much more serviceable to those who have to earn their
bread.
Section through the Joint — Has been recommended by Haynes Walton,"
and he gives a judicious warning against meddling needlessly with the
articular cartilages.
In the amputation above the carpus, such removal is bad surgery, as it
is followed by loss of pronation and supination in the stump, and great
injury to the utility of an artificial member. The presence of the
cartilages does not interfere with rapidity of union ; for they are cast off
in slireds during the suppurative process, and, even in large joints they
will disappear in a very few days.
Dr. Markoeb of New York supplies us with statistics on this operation.
The proportion of deaths, according to him, is 37 per cent, for amputation
at the knee joint, and 43J for amputation in the thigh. The value of
such statistics en masse is more than doubtful. There are many things to
be taken into consideration in the individual case, that can only have light
thrown on them by similar circumstances in other cases, and besides, the
statistics of one man differ materially from those of another.
Mr. Bryant has given a most painstaking table in the Lancet of March
12, 1859, containing much valuable information on the subject of the
causes of death after amputation.
* Lancet, November, 1859.
b New York Journal of Medicine, 1856.
I'l ■ I '
I /intation i/t the Child is contra-indicated below the knee,
of In Buch cases tin- limb c< grow at the Hune rati
the other, and the patient, when grown op, present* the di ible
I having hu two knees on different levels.
Amputation of the Ankle, — PirogofTs modification of Byrne's amputation
itt the ankle joint i> a \ aluablc addition to OUT resources; and to Pi]
or Eben Watson1 we are further indebted for an improvement in the mode
of its execution. This modification consists in first directly dividing tin*
parts down to the bone, by an incision from the tip of one malleolus
to the other, under the heel; secondly, Bawing tin- OS ealeis in an upward
and backward direction; thirdly, completing the posterior flap; fourthly,
making an incision in front of the joint, from one malleolus to the otb
ami finally, sawing off the malleoli. If the os calcis should prove
at all Carious its remains can be removed on the moment, BS converting
the operation into an improved and rapidly executed Syme's; but where
the bone is sound it has been found to unite to the tibia with wonderful
rapidity. In this operation, as elsewhere, caution in -election of cases is
required.
All new operations have first to run the gauntlet of injudicious support,
and afterwards of almost equally injudicious neglect. This oscillation
of professional favour will be in proportion to their importance and
magnitude. In the case under consideration it IS stated that Pirogoff
himself has abandoned the operation ; its success in the hands of others
demands, a reconsideration of this verdict. Mr. Svme gives it a determined
opposition : —
" The only other alteration worthy of notice is that of Professor Pin tgoff,
of St. Peteroburgh, who proposed to retain the tuberosity of the OS calcis by
Sawing it off before the disarticulation was completed, and thus, so far as
possible, depriving the operation of all its advantages ; in the first place,
by rendering it complicated instead of extremely simple; secondly, by
making the stump too long; thirdly, by impairing its constitution;
fourthly, by retaining a portion of the osseous tissue justly liable to the
suspicion of relapse; and tifthly, by not being applicable to all ca
requiring amputation at the ankle. On these grounds I have been accus-
tomed to regard the adoption of this modification as a certain sign of lax
surgical principle."*
It would have been more satisfactory had the energetic Professor of
the Northern Athens supplied us with some of his reasons for coming to
the above five conclusions.
HERNIA.
Pew subjects give greater proof of the desire of surgeons to improve
their art, than hernia. These efforts take three distinct directions —
* Lancet, June, 1859. Pirrie's Surgery.
b Observations in Clinical Surgery, p. 47. Reviewed in our present Number.
Progrx •ss of Surgery during the last Decade* 189
1 . Tlit' radical cure of hernia.
2. The reduction of hernia*
;>. [mproyementa in the mode of operation for Btrangulated hernial
Operation* for the radioed cure — Wttteer's operation for the core of
reducible inguinal hernia dates back to L838, buf was scarcely known,
and not practised in this country until Introduced to our notice by Mr.
Spencer Wells.* It appear! to be extremely successful in the hands of
the Bonn professor, of Bigmund of Vienna, and of Rothmund of Munich.
The last-named had operated on over 1,000 cases up to the year L858,
without a single death. Thin speaks strongly for the safety of the
Operation — of its efficiency, accounts are dubious, at least cases are not
sufficiently long under observation, except occasionally, for us to judge
of the permanency of success. Mr. Wells' paper in this Journal1' is so
ample, that we need only give the briefest description of the operation,
which, indeed, is now well known. The instrument consists of a central
plug, with two side pieces, which are capable of being detached, in order
to change them for larger or smaller pieces, according to the size of the
ring ; through the long diameter of this plug (which is a flattened cylinder),
one, two, or three curved needles can be passed, which make their exit
near the extremity on its upper surface ; this plug is thrust up into the
ring, invaginating some of the integument of the scrotum, the needles are
then inserted through the doubled skin and the sac, an external slightly
concave plate is now screwed down, so as to compress the abdominal
Avail and invaginated skin and sac together, with any degree of force that
may seem safe or advisable. The apparatus is left in situ from six to ten
days, and then cautiously removed ; the patient remains horizontal until
the needle punctures are healed, and wears a weak truss with a large soft
pad, for three months, in order to support the recent adhesions, and pre-
vent the retraction of the invaginated skin. Mr. Wells claims that in
strong patients, up to 40 or 45 years of age, when the hernia is of moderate
size, a perfect cure may be expected, and that in large hernice, which a
truss will not keep up, such reduction in the size of the ring is obtained
as to enable a truss to act efficiently. In our present number there is an
ingenious modification of Wutzer's instrument by Redfern Davies ; he
found that the gut was apt to slip down behind the plug of skin, owing
to an aperture of small size remaining unclosed in the upper part of the
canal. To obviate this, he makes his cylindrical plug in two portions,
connected at their outer extremities by a hinge, and capable of being
separated at their point by a screw and lever. Where Wutzer's operation
is adopted, this modification of his instrument deserves attention.
Wood's operation has almost supplanted Wutzer's. It has the advan-
* Medico- Chirurgical Transactions, 1854.
b Dublin Quarterly Journal, 1858.
/'/ iery during the I ' "U
t i m , i a,, t stretching the canal and ring ;n Wut uBtrument must da
It i^ a modification of the »>ld royal stitch; Lls principle is to p
end "i the thread Into tin- cana] and out through the -kin under one pillar
ad the outer ring; the other end of the thread \a passed up in like man
ler the inner pillar, and out through the lame opening in the -'.in.
Previous to passing the threads, a dissection of a portion of the superficial
.nd fascia propria lias been made through a small opening in the
upper part of the scrotum, and as much of tfa ible is invaghu
when the loop of the thread is drawn op. The ends of the thread
either tied orer ■ pieee of round bos wood, or -imply drawn tight without
any mterTening material.
Roubaix devised an autoplastic operation, by means <>f which a trian-
gular piece of -kin w;i> made to close the opening of the sac*
EL Davies has applied bis modification of Wutzcr'- operation to Femoral
and ventral hernia with BUCCec
l.ee has used a simple stitch like Woods', only that he brought out the
end- of the ligature at different openings in the -kin, and included a bridge
of -kin in the knot, the ligature v a- allowed to -lough out.
Svtne used a rectal bougie in place of Wut/.er's expensive apparatus,
passing his ligature through a hole in the end of the bougie. Other
minor modifications of these operative measures have been suggested by
many surgeons — their very number indicating that the operation i- a
disappointing one. Certainly it presents no feature to recommend it in
preference to the admirable truss long since invented by Mr. L'Estrange.
None of these operations act upon the internal ring, and none of them
effectually upon the upper part of the canal. All of them are applicable
to those hernia only which have descended beyond the external ring.
Now, Mr. L'Estrange's truss exercises pressure on the entire canal and
the internal ring. It is applicable to true inguinal hernia, as well as to
scrotal, and if the patient will confine himself to the horizontal posture,
a- long a- is needed after Wiitaer or Wood's operation, and will after-
wards wear the truss for a few months, he will be cured much more
certainly and permanently than by any of the other means.
Sir Astley Cooper long since laid down the principle that all trusses
must fail to cure hernia, unless they compress the canal and internal ring.
Mr. L'Estrange's truss fulfils the necessary indications. It makes its
principal pressure on the internal ring and neck of the sac, and the force
of the pressure lessens a- we pass down the canal to the external ring.
By this constant pressure, an escape of intestine from the abdominal
cavity is completely prevented, adhesive inllammation is set up between
the opposed surfaces of the sac, and a permanent cure effected. If the
patient wall lie for ten days or a fortnight after the application of the
* Gaz. Med. de Paris, December, 1855.
Progress of Surgery during the last Decade. 191
trass, Mr. [/Estrange assorts, the ••hit will be almost certain. Even
without thai precaution many patiente have, by its ose, been cured, not
only (•(' small reeent hernia, ltul of hernia of large SUB and old Standing.
Thia truss is now used extensively both in the army and nayy, and
has had testimony borne tO its efficiency, M a trUSf and ;i> a mrans of
eve, by the mosl distinguished Burgeons of the day. Omitting the names
of Irish surgeons who might be supposed to be prejudiced, it will suffice
to say, that Ferguson, [Aston, Byrne, Miller, among civil surgeons, and
Alexander. Bell, Carter, and Qibson, among military and naval, have
given it their approval ; that eases of radical cure by its use are recorded
under the hands of the most distinguished medical officers of both services;
and that the Academy of Medicine of St. Petersburgh has signified to
Mr. [/Estrange its approval of the principle on which it is constructed.
Seeing we possess such efficient and bloodless means of cure, our English
and German friends must forgive our apparent neglect of their ingenious
operations.
M. Bourjeaurda has devised a combination of elastic bandage and air
pad, which appears to be a comfortable kind of truss, but not efficient for
the radical cure.
Of injection of iodine into the sac (Velpeau, Jobert, Pancoast), or
subcutaneous scarification of the neck of the sac, nothing need be said.
They have almost passed into oblivion as means of effecting a radical
cure.
2. Modes of facilitating the reduction of hernia.
Malgaigne, Bransby Cooper, and Hilton,b succeeded in reducing
apparently irreducible hernia, by a prolonged use of ice to the tumour,
gentle laxative medicines (magnesia with colchicum), and sometimes the
full administration of opium, with dry diet and the recumbent posture, or
shoulders slightly raised.
In cases of strangulated hernia, Baudensc recommends ice to the tumour,
with compression, where it can be borne, and elevation of the pelvis.
Dr. Andrew Buchanan, of Glasgow,d suggests prolonged and forced
expiration, so as to use traction on the intestine by means of the upward
action of the diaphragm.
Other means of making traction on the intestine from the direction of
the abdomen, are depression of the shoulders and elevation of the hips,e
to which may be added the application of a jack towel or roller round the
abdomen/ the ends of which are pulled upwards, so as to drag up the
intestines.
* Lancet, Jan. 10, 1852.
b Medical Times and Gazette, May 28, 1853.
c Gazette des Hopitaux, August, 1854.
d Glasgow Medical Journal, July, 1856.
e An old method revived by Drs. Jessop of Cheltenham and H. Power.
f Wise, H.E.I.C.— Braitbwaite, Vol. xxi.
Progr\ u of Surgery during tli, D
In tlic Ifeath Hospital success in reducing a hernia ii frequently
attained by the use of a large cupping glass applied to th<- suri u e oi the
abdomen, close to the ring. This acta by dragging the intestine ai
m the sac, and by emptying the constructed portion
contents. For this very useful suggestion \\»- are indebted to th< ted
apothecary, .Mr. Parr, Strong and hot coffee, given in cupfuls every
quarter of an hum-, without milk and with very little sugar, icemi also to
have a wonderful power over the spasm of the intestine, and baa succeeded
in the hands of several practitioners in procuring reduction of obstinately
strangulated hernia.*
3. Operations for reduction of stratngulated hernia.
Baron Seutin of Brussels inserts his little finger gently along the
hernia, until be gets it within the ring; he then hooks his finger and te
the ring forcibly. By this means he has often succeeded in avoiding ■
cutting operation.
For femora] hernia Mr. Gay's minute incision at the inside of the ueck
of the sac-, immediately over Gimbernat's ligament, gains gradual favour.
It has the advantage of enabling the operator to «li\ ide the stricture almost
BUbcutaneously, by an insignificant wound, without, in the majority «<t
eases, opening the sae. By means of it the mortality of hernia i- reduced
50 per cent. Messrs. Fergusson, Luke, Paget, Birkett, ami many oth
fully approve of it, ami in a few years it will, it is to be hoped, be the rule.
The objection that at times the intestine and sae may be returned I
masse, holds equally to the taxis. This accident occurs because men forget
that taxis is nut, or ought not to be, at first a force exercised to push the
intestine back into the abdomen, but rather a gentle and even compression
of the tumour, by which it is sought to empty the intestine first of its
gaseous, then of it< feculent contents, before attempting to return it.
Let the taxis lie used properly, and very seldom indeed will the reduction
en bloc be met with.
The extra peritoneal operation is also applicable in some cases of
inguinal hernia, especially the more direct forms; and there is no reason
why the effort should not be made to reduce the intestine by means of it,
before resorting to an opening into the serous sae — always having due
regard to the mode in which the taxis should be applied. The whole
tpiestion of extra peritoneal operations for hernia was diseussed, at length,
in the last number of this Journal.5
Valuable statistics and conclusions on hernia will be found in a paper
by Mr. Bryant, in Guy's Hospital Reports for 1856.
(To be concluded in our next.)
* Durand of Havannah, Sanimut of Malta — Braithwaite, Vol. xxxvi., xxxvii.
b On Hernia, by Mr. M. H. Collis, Vol. xxxiii., p. 293.
Transactions of the College of Physicians in Ireland. 193
TRANSACTIONS OF THE ASSOCIATION OP THE FELLOWS
AND LICENTIATES OF THE KING AND QUEEN'S COLLEGE
OF PHYSICIANS IN LBELAND.'
SESSION 1861-G-
Fatm Meeting, Novembeb 20, 1861.
Dr. CHUBCHILL, Vice-President, took the Chair, and opened the Session
with Borne appropriate introductory remarks congratulatory as to the
continued prosperity of the Association.
Dk. CoRRlGAH exhibited, and gave the medical history of, two sub-
stances which he had lately found used in the Isle of Salamis, and which
were said to be a cure for hydrophobia. One, the Mylahris Graica, a fly,
found in the island, and which, when pulverised, is given with the powder
of the other, a plant — the cijnanchum erectum — in the proportion of two
parts of the plant to one of the fly, every second or third morning from
the time the patient was first bitten. The monks of Salamis asserted
that the fly was the same that was used for blistering by Hippocrates.
The symptoms produced by a large dose of it are, it would appear, similar
to those produced by powdered cantharides. Dr. C. was not quite
satisfied that this remedy deserved all the praise it received in Salamis,
where it was said to be an infallible cure, or probably, more correctly,
a prophylactic. He thought, however, that it was well worthy the atten-
tion of the profession in this country.
Dr. COBBIGAN also mentioned another peculiarity in the treatment, in
Greece, of persons bitten by rabid dogs, viz., the cauterization of the
part with boiling oil. He considered that this was, perhaps, a far more
effectual mode of so doing than the ordinary method adopted in this
country ; as it solidified all the surrounding tissues, converting them into
a dense mass, and arresting absorption.
Dr. Chubchill read the following paper: —
On Some of the Reflex Irritations resulting from Uterine Disease. — I have
no doubt, he said, that many of the members of the society are as familiar
with the reflex irritations to which I propose to call your attention as I
am : and not unlikely some may not only know more, but may be able to
throw light upon the best mode of treatment. That tiny have received
* These reports are supplied by Dr. B. G. Guinness, Secretary to the Association.
\ ul. XX XI 11.. NO. 65, N. 8 O
L94 ru of the Culteije of Physicians i/i lrel<
1 M ootice in i than they deserve 1 am certain, and that thej are
liable to be mistaken for other «li 1 know.
[ shall not jrour patience by attemptiii chaust the sub
but shall confine myself to a i«u instances, and those rtrictly limited to
or which 1 can answer, as having come under my own observation.
But it may simplify the matter it' I first describe 1 1 * * - disease which is
t frequently the origin or starting point of those reflei irritation-.
In patients subject to attacks of monorrhagia, especially in women who
have borne children; or after one Of linuv miscarriages from which
•very has been incomplete; or when both these circumstanc cor;
if we make an examination by the finger what we are almost certain to
find is an enlarged state of the body and cervix uteri, with increa
weight, Borne depression, and a patulous state of the os uteri. There will
probably also be more or Less tenderness, and a moist condition of the
vagina. It we examine with the speculum we may find, in addition,
that the mucous membrane of the upper part of the vagina IS <>f a much
deeper colour, brighter or darker, as the case may be, than natural; and
that there is an excoriation (I protest against applying the term ulceration
to this disease) around the os, and extending in different degrees OVerthe
cervix. The surface is deprived of epithelium, and looks raw; it may
be partly smooth or granular; and but rarely is the mucous membrane
entirely destroyed.
I have not intended to sketch a formidable disease, but a very common
one ; it does not affect life ; it never takes on a malignant character, but
I do not think it gets well spontaneously; it may last many years; it
interferes with important functions, and it gives rise to broken health.
If we feel any surprise at this we have only to remember that from 18 or
20 to 45 or 50, the uterus (and ovaries) are the very central organs of
female life; that the regular fulfilment of their functions i- as essentia]
quite to health as that of the heart, brain, or stomach ; and that devia-
tions are more sensibly felt in the ca-e'of the uterus than of any other
organ ; whilst the fulfilment of some of its functions involves special peril
to its integrity.
However, I do not propose to describe the general effects of uterine
disease upon the constitution, though there is much yet to be said upon
that subject also; but rather some of its more local effects.
1. Two years ago a lady, whose mother had recently died of cancer
uteri, told me that she was sure that she was getting that disease, in con-
sequence of a permanent sense of heat across the Lower belly. A tactile
examination enabled me to satisfy the lady that she was not suffering
from cancer ; but the linger revealed nothing else. A few months ago
the lady called upon me and told me that the uncomfortable sense of heat
had continued ever since, and that the catamenia had greatly diminished
Transactions of the College of Physicians in Ireland. L95
in quantity. An examination with the Bpeculum revealed an erosion
abort the size of sixpence, with some congestion of the cervix. I felt
ae hesitation in attributing her suffering to a cause so apparently
trivial; however, I proposed to tesl its influence by curing it, before
trying any other remedy for the heat
I applied the Btrong tincture of iodine twice a week, using nothing in
addition bul vaginal injections of cold water. The erosion soon began to
heal : and in exact proportion the sensation of heat diminished until it
entirely disappeared.
2. Some years ago 1 was asked to see a lady who was said to be
suffering From rheumatic pains, and also from whites. I found her com-
plaining of a pain apparently in the symphysis pubis, and a much more
severe one in the right knee, sometimes extending up towards the hip.
Much local treatment had been tried in vain. On examination I found
a very large excoriation around the os uteri, writh redness of the mucous
membrane and swelling of the cervix. I succeeded in curing this by the
usual means ; and even before she was quite cured the pains disappeared,
and did not return.
3. Last }rear I was consulted by a lady, October 28, who walked into
my study writh great difficulty, in consequence of a pain along the sciatic
nerve, from the hip, and extending sometimes to the foot. She could
neither stand nor walk without great pain, and her health was failing for
want of exercise and from continual suffering. She had no children ;
and a little inquiry induced me to think that there was something wrrong
with the uterus. On examination I found the organ very much retro-
verted from congestion and enlargement of its fundus ; and this, it
occurred to me, was probably the cause of the sciatica, either from
positive pressure, or, as the source of reflex irritation. I set about curing
the enlarged and retroverted condition of the uterus by cold injections,
rest, and the application of the tincture of iodine, and in due time the
organ regained its normal size and position, and the sciatica had entirely
disappeared ; the lady being able to stand and walk as usual.
4. Within a few months a lady was sent to me apparently labouring
under sciatica, for which everything had been tried. It was painful to
Stand, and still more to walk; in fact she could not walk more than a
very Bhort distance. The pain extended from the left hip down to the
knee; always present, even in bed; it increased in paroxysms, and in
the upright position. Her health had become impaired from want of
rcise, her digestion was deranged, her appetite diminished, and the
LStipated. She WAS scat to nie because she complained of
Bsional leucorrhoea, in hope- that, perhaps, some uterine disorder might
be detected sufficient to account for the pain in the leg. I examined, and
o •>
I n Ireland,
found the uterus « d, but not to any great dc the een
!, and there was as excoriation less in size than a shilling. Kotwith-
fche similar l had seen, I could hardly believe that tins
condition ol the Dterus— the congestion and erosion — had caused all the
suffering. However, the practical test I let about curing the
uterine affection; and, ai I succeeded, therein rive diminution
Ol the pain and lameness; and finally it ceased altogether, and tin: lady
can dow walk or dance as well as c\cr, to the great improvement "t her
genera] health.
I could give more cases; but these may surely suffice, as 1 do Dot wish
to trespass too largely on your patience.
I wish now to ask your attention to another form of reilex irritation ol
perhaps greater interest, because much more frequent, more difficult t«>
manage, and about some points in whose clinical history I am not quite
clear. I allude to irritability of the bladder dependent upon some form
of uterine disturbance. With the slighter and more evident cases I am
sure all are familiar; but the severer cases are not unfrequently treated
for disease of the bladder itself without success, so far as I have seen.
Perhaps the most familiar illustration I can give of such cases IS the
frequent desire to pass water in early pregnancy. Of course this may
arise partly from mechanical pressure and partly from reflex irritation
after the second month ; but I saw a case the other day in which it set in
immediately after conception, when it could not have been caused by
pressure.
The affection may be characterized either by an increased frequency of
passing water without pain or difficulty, or by the addition of pain to the
frequency, or by tenesmus, a painful and urgent effort to force out a few
drops after the bladder has apparently been emptied.
In the majority of cases nothing is learned from the urine ; it is natural
in appearance, of the usual specific gravity, not albuminous, nor depo-
siting mucous, and, on analysis, presenting its usual constituents. I have
met with one or two remarkable exceptions to this rule, however.
I need not say what a distressing affection this is. Even the minor
degrees give trouble enough ; but, when severe, the incessant irritation,
the frequent pain, and the loss of rest, wear out the patient, and render
her pale, languid, and exhausted. The general health soon suffers
from the functional disturbance, the appetite becomes fastidious, and the
spirits depressed, whilst the fear of some dreadful disease haunts the
patient.
Now, I have found this reflex irritation to arise from various conditions
of the uterus and vagina. I have known it occasionally in young
unmarried women, dependent upon menstrual irregularities, chiefly a
scanty secretion; upon acute vaginitis (not gonorrhteal), upon menorrhagia
Transactions of the College of Physicians in Ireland. l!»7
without erosion, upon congestion, or chronic inflammation and erosion
of tin- cervix, One remark I have made, viz., thai the amount of
irritability and distress may be very great, and the local lesion \<rv
small; or the reverse; in short, that the Buffering bean no proportion to
the primary disease.
Hut some one will probably ask, wh.it proof have I that this affection
i- only a reflex irritation? In the first place (with a few exceptions), the
urine preserves its natural composition, even though the irritation has
been of Long Btanding; and secondly (with few exceptions), you will cure
the vesica] affection without direct treatment, which I take to be con-
clusive.
But now for these exceptions. I have said that the irritability may
last for a long time with no change in the character of the urine. I have
11 this so after months or even years of suffering. Yet in a few cases
of long standing, where there was great tenesmus and pain, I observed a
mucous deposit, and even a little blood ; in others there was an increase
of the phosphates, or a deposit of purpurates.
In the majority of cases I do not think there need be any difficulty in
diagnosis, unless the inquiry should be limited to the vesical symptoms.
The natural condition of the urine, on the one hand, and some such
uterine derangement as I have described, on the other, will at least show
the possibility of its being of a reflex nature. An examination with the
catheter will ascertain that there is no stone in the bladder, and the relief
of the primary affection will be followed by the gradual subsidence of the
irritability of the bladder.
But in the severe cases, the diagnosis is not quite so easy. Symptoms
almost identical result from calculus in the bladder, and even an ex-
perienced hand may not always detect this. Not very long ago I was
asked to see a young lady who suffered very much from the necessity
of frequent micturition, especially at night, with tenesmus and some
pain. It was remarked that whenever the catamenia were irregular,
these symptoms appeared, or if present, were aggravated. She had
had intervals of complete remission, with relapses at different periods.
Although the condition of the urine led me to fear either stone or some
disease of the bladder, yet as she had been examined for stone before I
saw her. without any being detected, and as there seemed to be some
connexion between the irritability of the bladder and menstrual irre-
gularity, I set myself to regulate the latter, in the first place. Under
the usual treatment, after some time, she did menstruate, and there was
some improvement in the character of the urine, and a diminution of the
distress, but it was too slight to satisfy me, and I was allowed to examine
the bladder. After Borne time I succeeded in detecting a stone, which
was subsequently removed. Careful examination, I believe, is the only
means to be depended upon for diagnosis between these two diseases. I
' nil
n quite r«- Buffering when there was do stone. I recently
with Dr. Macready, where the frequency, the tenesmus, and
pain, were rery great, and where sometimes blood and sometii
muc l from the bladder. There was no itone to be discovei
and the irritabUity was relies ed bj injections, and by the cure <>f the eroei
to ilu- treatment of the simpL . 1 Deed Dot detain you Long.
Bui we must be on our guard against promising a speedy cure. The
or congestion will not be rapidly cured, and the relief of the
mdary distress may no! commence until the cure of the primary ca
i> Dearly complete. 1 have a lady under my care at present, who con-
sulted me three or four months ago for reflex irritation of the bladder,
and also of the breasts, which nearly resembled those of early pregnancy,
arising from congestion and erosion <>f the cervix.
The latter is now quite well, yet it is only a few weeks that these
reflex irritations ha\e ceased to trouble her. I gave do remedies for them.
The first point 18, to make sun1 that there is no stone, by a careful
examination, and no organic disease, and then cure the primary affection
Each one has his own pet remedy, probably; some ase nitrate of diver —
some more heroic applications. For myself 1 have found an occasional
touch of nitric acid, and the regular application, twice a week, of strong
tincture of iodine, with syringing the vagina daily with cold water, the
most effectual remedy. After many years' experience, I must say, that I
know of no application to be compared to the iodine ; it not only diminishes
the congestion and cures the erosion, but it reduces the bulk of the
uterus. If, how ever, there be any vaginitis, the iodine ought not to be
used until that is cured, which will probably be best effected by a solution
of nitrate o\i silver.
If the menstruation be in excess, it must be controlled, as otherwise we
shall hardly cure the congestion. I have found that this can be done
either by ergot, Indian hemp, gallic acid, or Ruspini's styptic.
In thi' severer cases, when we have satisfied ourselves that there is no
Stone, 1 use the same remedies, local and general, as in the simpler oi
but, in addition, I have found great advantage from throwing into the
bladder a solution of nitrate of silver (gr. v. to gr. x.) with a little (gr. ii.
to gr. v.), of the extract of Belladonna, or (gr. ii.) watery extract of
opium. This should be retained a few minutes and then expelled. It
generally gives pain the first time, but less afterwards, and it may be
repeated two or three times a week until relief be obtained.
I need hardly say that the state of the constitution and general health
should be carefully regulated, if necessary, but in many cases I have
found the local treatment all that was required.
Dr. Osborne gave the result of his experience in the use of the
Harrowyate waters.
Reports of ike Dublin Pathological Society, 199
He considered thai the effed of these waters iras very generally mis-
understood. They were Baid to be purgative; bnt I)'-. 0. was of opinion
that this was not the case. Any effed they had in the we>y of a laxative
was on the small intestines; bn1 the ascending colon would be found
plugged. Ii wm necessary to use purgatives whil-t taking these waters;
For, though the digestive organs were apparently in full vigour, a false
diarrhoea was established which could only be relieved by free purgation.
He said thai the principal spa was, in its const it uents, nearly identical
with sea water.
The Second Meeting of the Session was held on 18th December — Dr.
Fitzi'a i i;n k in the chair. The Association adjourned, without trans-
acting any business, on account of the recent death of the Prince Consort.
PROCEEDINGS OF THE PATHOLOGICAL SOCIETY
OF DUBLIN.*
Twenty Fourth Annual Session — 18G1-C2.
Ligatured Artery. — Dr. Bennett exhibited a specimen which showed the
changes that occur in the arteries of the thigh after ligature of the super-
ficial femoral, for the cure of aneurism in the popliteal space. The man,
aged 50, from whom the specimen was taken, died last wreek in Sir
Patrick Dun's Hospital, of disease of the lungs. He had been operated
on at Jervis-street Hospital about four years ago, and was discharged
cured. At the post mortem examination the clinical clerk removed the
specimen, but under unfavourable circumstances, which accounts for its
not being as perfect as it should be. The common femoral is of its usual
size, and presents no change except a slight atheromatous deposit in its
coats. The superficial femoral is contracted to less than half its natural
diameter, from its origin down to the seat of the ligature, a distance of
two and a-half inches. At the seat of the ligature it is completely closed
for about half an inch, and from this point down to the origin of the
anastomotica magna is again open, and of about the same diameter as the
upper patent portion. Beyond the anastomotica magna, the popliteal
portion of the vessel is converted into a fibrous cord, as far as the remains
of the aneurismal sac, which is about the size of a large filbert, and has
undergone calcareous degeneration to such an extent as to require the
saw for its all ision. Below the tumour the vessel is obliterated as far as
it has been removed. The profunda femoris, and its branches, are
enlarged to nearly double their normal size, as i- to be expected in con-
* These reports are furnished by Dr. R. W. Smith, Secretary to the Society.
200 I ' Dublin Pathological &
of their having to oarr) on the circulation of the limb,
principal points of interest in the specimen arc the ihort extent of the
ilusion of tl el at tin- seat of ligature, and iti patent condition
bekw this point to the origin of the anastomotic branch, which \^ Uu
than normal.
The former of these peculiarities is accounted for bj the ocenrrence of
two small branches, one immediately above, and the other below the
ligature. This peculiarity has been observed in a large Dumber of tlie
reported cases. The latter |>«>int of interest, namely, the patent condition
of a large part of the vessel below the seat of Ligature, ami the increased
the \ esse] leading into tin- end of the patent portion, shows thai the
stream in the anastomotic artery was reversed, and that this vessel must
have circulated the blood through the sac tor a time after the application
of the ligature, and so led to its gradual obliteration. This point -hows
that the principles of the Cure of aneurism, by ligature, and by pressure,
are the same — namely, the diminution, not the Stoppage of the stream
through the -,i<\ BO as to favour a gradual deposit of fibrin, and not the
coagulation of blood in the sac. This conclusion is borne out by the
phenomenon of recurrent pulsation, which OCCUTS in the sac BOme short
time after the operation in most eases, indicating that the collateral cir-
culation has been established. — November 80, 18G1.
('amrr. — Mr. M. II. COLLIS Said he was indebted to Mr. Smyly for
the opportunity of bringing forward a case of cancer, which presented
some peculiarities. Knowing the interest he took in sm-h subjects, lie
kindly allowed him to be the medium of offering it to the Society. The
patient was a woman about 50 years of age, and exceedingly hale and
healthy-looking — the mother of two children. About a year and a half
she met with a hurt, and immediately afterwards observed a small
tumour, about the size of a walnut, or rather less, in the breast. It
merely gave her mental annoyance until four months ago, when it
ned to grow rapidly; she cannot say whether she received a second
injury then ; she complained of occasional darting pains, of some
severity, but the distress of mind from the presence of the tumour
annoyed her more than the pain, and she wished to have the tumour
removed. Upon presenting herself at the Meath Hospital, about a week
ago, the surface of the tumour appeared to be extremely red, and the skin in
the neighbourhood was of an erysipelatous tinge. The skin over the most
prominent part of the tumour, though not adherent, was tightly stretched.
There was also considerable enlargement of the glands in the axilla. In
the neighbourhod of the tumour tubercles of a small size were distributed
over the skin, and there were suspicious points of redness scattered about
in the region between the two breasts. Her condition was most un-
favourable for operation, and it was a question for consideration, whether,
Reports of the Dublin Pathological Society '"1
under the circumstances, they would be justified in interfering. They had
her earnest wish, however, for the operation to guide them in their
decision, and this mainly led Mr. Smyly t«> operate. She said if it were
not removed Bhe would "hack it oft herself,'1 as she was determined not
to return home with the tumour on her. Sometimes, after removal of
tumours in this condition, the skin heals with great rapidity, and,
although the disease inevitably springs out afresh, the patient has ■ con-
siderable interval of ease, and this was a further Inducement to yield to
her request. As to her chances of permanent benefit from the operation,
they were very small. Much evidence could not be derived from
statistics on the subject ; statistics did not apply to special cases; those,
however, collected by Mr. Paget were rather favourable to operation, when
it could bo done in the early stages of the disease. Mr. Collis here
exhibited the section of the tumour, and proceeded to remark, that there
were, at least, three remarkable points of interest about the growth.
Upon the thinner lower portion of the tumour they found a hard, dense,
resisting, semi-cartilaginous material. Where the growth was of rapid
development, it became softer — of a grayer colour — much more elastic,
and yielding a larger quantity of juice on pressure, or when scraped.
Again, where the skin was most tightly stretched, there was a large
amount of vascular tissue intermingled with the encephaloid material.
They had in this specimen examples of three varieties of cancer —
encephaloid, schirrus, and that degree of encephaloid which was about to
become fungus nematodes. — November 30, 1861.
General Paralysis of the Insane. — Dr. Banks made the following com-
munication, and exhibited the brain and frontal bone.
A man, aged 25 years, was admitted into the Richmond Lunatic
Asylum, on the 27th of October, from the Whitworth Hospital, where he
had been for three weeks previously, under the care of Dr. Gordon.
His mother stated that he had convulsions in infancy, but, with the
exception of that attack, he had enjoyed good health. At the age of 13,
being then a remarkably strong boy, he was kicked by a horse in the
forehead, and remained in a state of insensibility for 24 hours after the
receipt of the injury. In the progress of the case, small pieces of bone
came away from the wound, which, however, was perfectly healed at the
expiration of two months, leaving a deep depression of a semicircular
form on the forehead. He was occasionally noisy and restless, and
difficult to be managed ; but there was no marked change in his condition
until the morning of the 27th of November (one month from his
admission), when he was seized with epileptiform convulsions, which
recurred at intervals until his death, which took place in 3G hours. He
was perfectly unconscious from the moment of the seizure.
The necropsy, performed 24 hours after death, revealed the following
Dublin I ty.
morbid appearances: — On dividing the toalp, it was found to
w it li i.l 1, and at the situation of the deep depression on the forehead,
it p intimately attached t«. the frontal bono, that it was v.ith
difficult) removed, and the bone itself bad i ponding to the
cicatrix, of considerable depth.
On the interna] surface ol the frontal bone there was also s '/move,
ami to it the dura matter closely adhered. In the neighbourhood ol the
depression, the bone was extremely thick and dense from the deposition
us matter. On the mrface ol the brain, corresponding to a ridge
at the seat ol the fracture, there was a well-marked depression, and ben
the cerebral substance was hard ; and in this part, whieh was probably
the remains of a cicatrix, Dr. Bennet, who made an accurate examination,
found a little hard mass, which was evidently bone. The consistence of
the brain was normal, hut there was extreme vascularity of all the
contents of the cranium. There was slight opacity of the arachnoid
membrane. The spinal chord was not examined.
This case is interesting, from the fact of mental alienation, associated
With general paralysis, OCCUring in a person who, thirteen years pre-
viously, had received an injury of the brain. How much the fracture of
the frontal bone, and the lesion of the cerebral substance beneath,
contributed to the production of the disease, is difficult to determine.
For thirteen years, the patient appears to have been in the enjoyment of
mental and bodily health.
The course of the disease, which proved fatal, was unusually rapid,
(three months.) "With respect to the pathology of general parah -
it may be observed that there is nothing constant. There was no want
of intelligence observable in the boy, his capacity appearing to be equal
to that of most young people of his age. When In1 grew up, his habits
were irregular; he was intemperate, and he had syphilis more than once.
Three months before his admission into the Asylum, he had a lit, which,
from the description, must have been epileptic, and after this his
family noticed a complete change in his manner; to OSS his mother's
words, he took strange fancies in his head, believing that people were
conspiring together to injure him, &c, &C "While in the Whitworth
Hospital, he was heavy and stupid, slow in answering questions, and at
times incoherent. He presented, on admission, the ordinary symptoms of
the general paralysis of the insane; his articulation was very imperfect;
there was a tremor of his tongue and upper lip, and he was unsteady in
his gait, the muscles having lost the power of co-ordinate action.
Calmed, after detailing the morbid appearances observed in many
oases of this most hopeless form of disease, says the disease arises from
11 some one modification of the brain, whose nature we have not yet
learned to appreciate." Notwithstanding the labours of Bayle, Esquirol,
and other distinguished alienists, at home and abroad, in this field of
Reports of the Dublin Pathological Society. ^0.°>
inquiry, Little light has been thrown on th«' pathology of general paralysis.
The conclusion of Dr. BuckniU is probably correct, who believes that
"general paralysis is a disease of nutrition, affecting the whole nervous
bj stem."
The subject, however, is one which is well worthy the attention of all
who arf engaged in the investigation of the pathology of mental disease. —
November 80, L861.
Aneurism of the Ah, luminal Aorta, — Professor Macnam \k.\ said, that,
by the kind permission of Professor Stokes, he was enabled to lay
before the Society a specimen of aneurism of the abdominal aorta.
The man had been Ben! to Mr. Macnamara sonic two years ago, suffering
from severe pains in the lumbar region, the cause of which was very
(cure. At firsl he (Mr. M.) was inclined to ascribe them to some
renal affection, in which supposition he was, to some extent, borne out by
the state of the urine, and prescribed some trifling remedies, which, for
the time, gave relief, and he lost sight of the patient until the month of
August last, when he returned, complaining of the pain being worse than
ever, upon which occasion he was taken into the Meath Hospital, under
the care of Dr. Hudson. Mr. Macnamara held in his hand the report of
the case, and of the post-mortem examination, as taken by his friend, Mr.
Arthur Wynne Foot, which entered so fully into every particular as to
leave him little else to do than read the report, and show the morbid
specimen.
John Mullen, aged 54, married, was admitted into the Meath Hospital,
under Dr. Hudson, August 19th, 1861, suffering from severe pain in the
spine and loins, and stiffness of the back. For these symptoms he could
assign no cause; he had never been a day ill in his life, and had not
strained himself. It was soon ascertained that he had been very intem-
perate, and that the larger arteries were diseased. The first attack of
pain occurred four years before admission, and was referred to the left
kidney. This pain did not remain very long; but for the last two years
there has been pain constantly present in the lower part of the spine, in
each lumbar region, spreading over the back, and, within the last three
or four months, shifting downwards into the left hip joint. This pain
was Less acute when the bowels were free; and, when it was very severe,
hi- urine was clear, and free from sediment; whereas, when he was in
comparative ease, the urine, regained its usual turbidity, from deposition
of lithates. The decubitus which he found most comfortable was on his
back. At an early period of his illness, he lay on his face with relief,
but. after admission, could only keep in that position for a few minutes.
ding or Bitting were attitudes he was very reluctant to assume.
On the 19th of August, the hand, when applied to the left side of the
lower dorsal vertebra;, felt a pulsation outwards, over a space about four
204 I: | 1 1 i '' />■ fjTi Pathological Society
inches long. In tlii> situation there was s fulness, but no distinct tnmoor.
Pressure on this part did not give pain. A mnrmnr vsa- wi\ distinctly
heard there whilst la- was in the recumbenl position, but disappeared on
his sitting op. A rough murmur was heard along the whole Length of
tin- spine. The hearts impulse wo iolent^ tilting up the lower ribi
U contraction. He ii much distressed l»\ this violent action, which is
always in proportion to tin- severity of tin- pain.
Aui:u>t 23rd. — Murmur and pulsation were evident from tin- infi
angle of left scapula to the crest of the ilium a( ride. Bj de
tumour became evident at the left side of the lower dorsal vertebrae, and,
on the oOth of September, there was, in that situation, a large, well-
defined prominence, with strong, eccentric pulsation, the seal of burning
pain, shooting thence into the epigastrium, and down to the heeds. Finn
pressure on the abdomen relieved for a time this sensation, hut painting
the tumour with tincture of aconite was more effectual. The pain was
always worst at night. During this time there were evidences of the
advent of another tumour on the light side of the spine, opposite the
middle dorsal vertebra. Pulsation, fulness, and at last a distinct tumour
appeared the second week in October, at the inferior angle of the right
scapula. In neither tumour was there any murmur now heard, but the
pulsation was most marked. About this time he suffered much from
anesthesia in the lumbar regions, and had some attacks of most violent
pain, during the continuance of which the expression of his face was an
index of the intense agony he suffered, and for the relief of which large
doses of opium (sixty minims of the liquor opii sedativus) were all but
ineffectual. His greatest relief was afforded by brandy, which alleviated
the pain in a wonderful manner, when opium, hyoscyamus, and other
sedatives, proved useless. During all this time, the average rate of his
pulse was 80 beats in a minute.
November 7th. — A transverse pulsation, connecting the two tumours
beneath the -pines of the vertebra', began to be felt, and there were signs
of diffusion of the tumour. On the 23rd of November, the left nates and
upper part of the thigh were (edematous ; the lower tumour measured
eight inches in length, by seven in width ; the upper one five inches long,
by four and a half across. His great difficulty was now how to lie with-
out pressing upon either prominence, and a trial of every means to effect
this failed in accomplishing its object. He was found dead in his bed at
3 o'clock, a.m., December 2nd, 1861, having expired without a sound.
Post-mortem examination, seven hours after death. — Body cold ; surface
very much blanched ; muscles in front of chest, thin, soft, wasted ; no
fluid in pericardium ; surface of heart, especially right side, loaded with
fat ; valves healthy ; organ not enlarged, but, on the contrary, rather diminished
in size ; muscles of left ventricle soft ; of right, very soft and thin.
Aorta, from commencement, full of patches, slightly raised, of light
Reports of the Dublin Patholoyiail Society. 20;")
yellow deposit. Left lung adherent to ribs, nearly ereiywhere ; lobular
emphysema in Lower Lobe. Some fluid in bottom of pleural cavity. In
abdomen, abort two pints of yellowish fluid ; no peritonitis, recenl or old.
Intestines were empty. Behind the peritoneum the cellular structure was
all black, from extrayasated blood, as were also the muscular coverings
of the tumours. When the cheel and abdomen were eviscerated, two
tumours came into view, presenting no rupture on their anterior aspect.
The body was turned round, and an oval portion cut out, including the
vertebrae from the middle dorsal to the fourth lumbar, extending as far
outwards as the angles of the ribs. The muscles on the left side of the
back were infiltrated with blood, softened, and decayed ; mere pressure
of the linger was sufficient to break into the sac, when the integument
was removed. On slitting up the abdominal aorta along its whole
Anterior aspect, a rent was seen in its posterior wall, four and a
half inches long, opposite the last dorsal and three first lumbar
vertebra), leading into an enormous double cavity on each side of
the spinal column; that on the left side being about nine inches long in
Its greatest diameter; that on the right, four inches — this was fully
] tacked with coagulated blood, whilst the lower portion only of the cavity
on the left side was so occupied — the ribs on the left side slightly, and
the vertebras deeply eroded, formed part of the sac, whilst the interver-
tebral cartilages had suffered but slightly.
Mr. Macnamara then proceeded to draw the attention of the members
of the society to this specimen. The tumour on the right side was now
more prominent than that on the left, in consequence of the latter having
been, to a great extent, exhausted of its contents by the infiltration of
the blood into the neighbouring muscular structure which posteriorly
formed the wall of the sac, and which was so completely disorganised
that he had no doubt that, had the patient lived a few days longer, the
slightest motion would have caused its rupture, and the death of the
patient from hemorrhage ; a form of death, which, as matters now stood,
he did not think this patient had undergone. Mr. Macnamara being now
inclined to attribute the cause of death to enfeebled cardiac action, and
consequent fatal syncope, rather than to hemorrhage, the quantity of
blood effused evidently being the result of a slow creeping exudation
rather than of a rapid gush, and, although considerable in quantity, still
not sufficiently so, per se, to be attended with a fatal result. The con-
dition of the heart threw great light on the benefit that the patient
experienced during life from the exhibition of stimuli. The post mortem
imination also disclosed the interesting fact that its violent action
during Life was not due to hypertrophy of the organ, but to fa jmsition,
superimposed on the sac of the aneurism, which communicated to the
I. :i Its own impulse, giving rise to that "jogging" action to which
attention had first been drawn by Dr. Hope. The extraordinary size of
Dublin Pathoh ty.
tlu- rent through which the blood had become diffused \ irk-
able feature in this interesting it being fully, a^ the members mi
the length described !>\ Air. Foot. The unhealthy condit
the artery itself was worthy of observation, the coats being capable
■I'll with the wry slightest effort, and thicklj studded with
atheromatous deposit. The communication between the sacs on »ithrr
tide was in front of tin- vertebrae, ami perfectly open. The rertel
themselves bad undergone considerable destruction, their bodies bcin<r
deeply eaten into, whilst the intervertebral cartilages exhibited hut slight
alteration, and that the corroding action was not limited to the
n examination of the ribs would prove, those on the left side
being sensibly eroded. These were the most remarkable features of this
most interesting case of aneurism, which Mr. Biacnamara con
worthy of the attention of the BOCiety, on account of its great Size, the
stence of the double tumour, the vast opening in the sac, the greatly
diseased state of the \cssel, the long duration of the disease, and tiie
it obscurity attending its diagnosis previous to its coming under Dr.
Hudson's care. — December 7, 1861.
ClrrJiusis of the Liver, — Dr. MacSwinky exhibited the liver ami spleen
taken from a man who had been under his care in Jen iial.
He died about a week ago, and his history might be thus briefly stated.
He was forty years of age, and about ten wars ago began to feel in
failing health, lost appetite and flesh, had frequent rick headaches, and
was subject to vomiting. After Buffering under these symptoms for some
time, he commenced to feel distress in the abdominal region ; which, lie
became aware, was somewhat swollen. He sought relief in the Richmond
Hospital ; had the operation of tapping performed by one of the surgeons
of that institution, and came out quite recovered. He did not describe
anything indicating an acute attack of peritonitis at this time, lie fol-
lowed his trade of a painter pretty regularly; but was a person of \ery
intemperate habits. He Buffered, from time to time, from derangement
of stomach and general ill health. lie came to Jervis-street Hospital
sixteen davs ago, and presented the following symptoms: he had enormous
ascites. There was total loss of appetite, and he was very much wasted.
His aspect was drowsy, heavy, and vacant, and he was most unwilling
to answer questions. He complained of extreme weakness. Although
he was not jaundiced, his skin was of an unusually dusky, sallow tint,
and the conjunctiva' were yellow. lie passed urine in small quantities,
it was high, coloured, and deposited red lithates copiously. The diagnosis
inferentially made, was, that he was suffering from cirrhosis of the liver,
and palliative remedies alone were given. A jwtt mortem examination was
made by one of the most industrious students of the hospital, Mr.
O'Dwyer. The liver was small, and the spleen very large. He believed it
Reportiofihe Dublin Pathological Society. 207
was pretty generally held, as the result of experience, by physicians in
this country, that enlargement of the spleen bore a tolerably regular pro-
portion bo ill*- diminution of the size <>(* the li\ er in cirrhosis ; the spleen, in
feet, Beeming to make an effort t<> perform the duties of which the liver
was do Longer capable. II*' knew it wee Dot so held by foreign authorities,
nevertheless it was probable the fad was so. The liver, in that case, did
not present many, or very well-marked nodules, but there were some
portions ot' it elevated, whi.-h there could be, he believed, no doubt, were
due to the contraction of the cellular tissue, or so-called capsule of Glisson,
which was always met with in the disease. Upon making a section, a.
Dumber ot" -mail, roundish, distinctly granular, dark-grey coloured bodies
might he perceived constituting the interna] Mmcture of the nodules.
These granules were divided from each other by whitish bands of hard,
dense tissue. He might mention, that Mr. CDwyer had observed, when
making the autopsy, a considerable amount of thin filmy membrane which
completely matted the intestines together, and could not be easily broken
up, an infallible proof of some antecedent peritonitis. The disease was
usually found to exist in spirit drinkers, and it did so in the present
instance. It occurred to him that it was produced, in the majority of
cases, from the direct action of alcohol on the organ — and if this was the
case, if it were caused by the action of alcohol imbibed in an undiluted
state, and passing through the liver more or less undiluted still, it would
be in accordance with the opinions of Lallemand, Duroy, and Perrin, as
expressed in their recent work, uDu Role cle V Alcohol" that no decomposition
or destruction of the spirit ever occurs in the system, but that it is
eliminated sooner or later, as the pure alcohol it had been imbibed. That
was. as was known, contrary to the opinion of Liebeg, but, of course, he
would not enter further into that question now. — December 14, 1861.
Tuberculosis. — Dr. Moore exhibited part of the viscera taken from a
man, aged 32 ; he was admitted into Mercer's Hospital on the 1st of
November, suffering from uncontrollable diarrhoea ; he had all the appear-
ance of one labouring under extreme anemia and exhaustion, the result of
general tuberculosis, he was oedeniatous and ascitic ; he passed urine in a
diminished quantity; there wras no evidence of special cardiac or pulmo-
nary disease; the liver was enlarged, and he complained of great pain in
the hack. On examination the urine was almost solid with albumen.
The diarrhoea was partly controlled by treatment; and attention was
then direct.-d to remove the ascites, but without any sensible effect. At
tin- end of some weeks he complained of violent pain at the base of the
right Bide of the thorax, tin- was alleviated, hut it left him totally pros-
II.- died "ii Wednesday last. On making an examination of the
viscera, the kidneys weighed between seven and seven ounces and a-half,
and were slightly enlarged.
Dublin Paiholo
Besides this enlargement and increase in weight, the cortical substance
completely anemic, and only a fen vessels <>i ■ stunted app<
could be seen in it ; the cortical substance vras much increased in dianu I
its surface smooth and covered with an opaque fluid; the pyramid! «
oi a pale red, their base presenting a rugged appearance from the exten-
sion of the cortical substance between the tubuli. On the whole, they
presented a very good specimen of fatty renal degeneration, as described
by Bright.
The liver, which, during life, filled the right halt of the abdomen
far down as the iliac region, weighed five pounds and a half, the right
lobe being especially enlarged; it presented a nodulated, uneven, fed to
the hand, and on cutting into its substance, yellowish oheesy deposits
about the size of a large pea were observable; these masses were much
larger than similar deposits usually met with in the lungs, but i
isolated, and did not appear to exceed a dozen in number. The liver, in
general, was pale and triable; there were no tubercular deposits in the
spleen. The mesenteric glands were enlarged, and the intestinal tract
generally showed evidences of a chronic inflammatory condition.
On opening the thorax, the heart and pericardium were enveloped in
tat, the right lung was adherent to the diaphragm. In the substance of
this viscus, there were traces of recent tubercular deposits, and the lower
half of the Lung generally was engorged; the upper portion of the right
and the whole of the left lung seemed free from tubercle; the bronchial
and cervical glands were enlarged. This case is interesting as a specimen
of hepatic tuberculosis; this viscus not being so frequently the seat of
tubercular disease as is usually supposed, and rarely as a primary
affection. It must, therefore, be regarded as an evidence of advanced
tuberculosis generally. — December 14, 18G1.
Osteosarcoma. — Mk. Hamilton presented a femur with this disease,
ami said, that the man from whom the specimen was taken had felt some
pain in the lower part of the femur for some months, and there was
slight swelling near the knee, but he was not prevented from following
his usual pursuit in the engine department of one of the railways. On
one occasion, when walking, his foot came against something, and he fell,
and broke his thigh. He was seen by Mr. Burke, of Phibsborough, and
treated in the usual way for broken femur. At the end of six or seven
weeks, it was found that his general health was suffering, and Mr.
Hamilton was asked to see him in consultation with Mr. Burke. The
man was apparently perfectly healthy; he was about 28 or 30 years of
age ; but he was much too fat for a person of his time of life. On
removing the splint, he found an ununited fracture. The thigh, at that
part, was perfectly flexible, and there was, besides, a considerable degree
of swelling at the seat of the fracture. There was a solid wall of bone
Reports of the Dublin Obstetrical Society. 209
on the outside, and ii appeared not unlike a necrosis, the bony ease of
which had given way. There was no alteration of the axia of the femur,
■or shortening, which waa rather peculiar under the circumstances,
There was do eversioo of the foot He recommended a starch bandage,
and saw n<> more of bim for ten days or a fortnight, when In- came to the
hospital, and waa admitted. The swelling was then *ery considerable ;
the starch bandage waa aol removed, bul the elder attention waa now
directed to his cheat He Buffered from difficulty of breathing, cough,
and hemoptysis, and. on examination, there waa complete dulneaa under
the left nipple, absence of respiration, and no rale of any kind. After a
short lim.-. he grew rapidly worse, and died. The thigh bone presented
a very good Bpecimen of malignanl disease. It was a ease of malignant
Msarooma. A large oval tumour occupied the lower third of the
femur, and extended a short distance from the condyles of the femur. It
felt now different to the touch from what it did when he first saw the
man. There waa now a softness in the feel of it, and a certain degree of
elasticity. When a section Avas made of the tumour, the thigh bone in
the centre had disappeared; the tissue was firm and elastic in one part,
and in another it was soft and blood-coloured. The drawing, by Mr.
Connolly, exhibited the appearance of the bone on examination, and
showed the deep colour of the medullary portion of the tumour. He
formerly exhibited a tumour of the same character, but occurring in a
different bone — the humerus; and it wras very interesting to compare the
two. This man fractured his arm by leaning on his elbow; but there
was scarcely any bony case in that instance. — December 14, 1861.
PROCEEDINGS OF THE DUBLIN OBSTETRICAL SOCIETY."
TWENTY-FOURTH ANNUAL SESSION, 1861-62
First Meeting, Saturday, 23rd November, 1861.
Dr. M'CLrxTOCK, in the Chair.
Arrr.n some prefatory remarks suitable to the occasion, Dr. M;Clintock
exhibited to the meeting a number of highly-finished coloured drawings
(from tin' pencil of Mr. Conolly), and preparations, illustrating the
pathology and treatment of Tumours of the Labia, Clitoris, and Vagina,
accompanying each of these with a concise history of the case from
whi<h it waa taken. The tir-t group exemplitied the non-maH<jn<i.itt
tumour- of the labia, and contained four cases,
* These report! rue supplied by Dr. Geo. H. Kidd, Secretary to the Society.
\ I 'I. \\ Mil.. \<>. ii,"), N. S. p
210
Repw h of the Dublin ( I
Cv-: | Fibrous Turn Right Labium, The morbid growth, which
squalled in kly globular, and excoediri
dense and close in it- structure. At its motl dependent part the Labinm
was ulcerated to the extent a dollar would cover. This ulceration
involved the entire thickness of the labium covering the tumour, and
exposed the surface of the latter. The patient, from whom this labium
was removed, was a countrywoman about 1<> years of age, and had borne
i-al children. Fifteen years had elapsed since she first perceived any
enlargement of the part. She had experienced do annoyance whatever
from the tumour, excepl what simply resulted from its hulk and weight
The enlarged labium retained its connexion with the pelvis by a Deck
about equal in size to three fingers; this was divided with a bistoury,
and the resulting wound healed satisfactorily. The woman was a patient
of Dr. Brunker's, of Dundalk, by whom the operation was performed.
Cask II. — Syphilitic Hypertrophy of Left Nympha. A young woman, of
rather questionable character, was confined in the Lying-in Hospital of
a premature child — her first, Bhe said. It wa8 born dead, and far advanced
in decomposition. The left nympha was about the size of a large turkey
egg, its surface dark coloured, and deeply fissured. This great bulk of
the part was owing, in some degree, to oedema, which disappeared soon
after delivery, leaving the tumour more dense and rugous, though
diminished in si/.e. She had the remains of a leprous eruption on different
parts of the body. She would not listen to any proposal for the extirpation
of the tumour, which did not Beemto cause more than very trifling incon*
vt nience.
Fig. 1.
Cask III. — Tuberculated and Enlarged Nymphce; Ecrasement. This woman
was aged 85. She was 10 years married, and had one child, nine years
ago, which was dead born. She got a venereal complaint from her
Reports of the Dublin Obstetrical Society.
21]
husband soon after her marriage. The enlargement <>f the oymphse lias
been coming on for the lasf rii months, and each is now nearly as largo
1
as a hen's egg. They are of a pale pink colour, and deeply divided by
fissures, so as to present, in a very striking manner, a tuberculated or
lobulated appearance. She menstruates regularly, but has a constant
yellowish watery discharge from the vulva, with much pain and soreness
of the part, so as to render sexual congress quite intolerable for some
months hack. Having put her under chloroform, Dr. M'C. removed the
two nymphae simultaneously, using two ecraseurs in order to expedite
the operation, which altogether occupied 15 minutes. Some hemorrhage
from a small artery took place, but was restrained by cold and continuous
pressure for the space of two hours. Her recovery was rapid and com-
plete.
( \se IV. — Enormous Enlargement of Clitoris and Ngmphce; Extirpation,
A countrywoman, aged 30, came under observation in March, 1856,
when in the seventh month of her second pregnancy. She sought advice
on account of the condition of the labia minora, and was admitted into
one of tie- wards t'<»r diseases of women in t lie Lying-in Hospital. Nine
its previously -he contracted venereal disease from her husband.
■ut two yean ago the nymphae began to enlarge; and within the last
few months they have increased very rapidly. Three large tumours
hung down from the genital fissure, of a pinkish red colour, slightly
P 2
R / 1
itous, and eerj tuberculated. The centre kumoc khe clitoi
enlarged to the size of a turke and l>>
to ■ procident uterus. On either ride ol tin- were the nymphse of
immense magnitude and of verj irregular figure. The fissures and clefl
these grow ths were abraded, and j ielded an abundant yellon Lab dischai
\ the enlarged clitoris might haw interfered with parturition, its
removal ires deemed adi isable, and was effected in the following manner: —
ilk ligature was applied around its pedicle ( which about equal
the thickness of a man's thumb), and three days afterwards it was excised
below the line of strangulation. The remains of the pedicle separated some
days later, leaving a healthy granulating surface, which healed Batisi
toriry. The woman was now allowed to go home foe her coiilinrinent ;
some weeks after which event she Came hack to the hospital. The neck
of the growths now remaining about equalled the middle, index, and ring
fingers. This was divided into three equal portions, each of which was
included in a separate ligature applied as tightly as possible. Very oon-
siderable pain was thereby occasioned. On the next day the strangulation
of the tumours was found not to be complete, and the neck of the growth
WSJ again included in two separate ligatures, which caused very acute pain,
lasting for many hours. Two days after this the whole mass was removed
with the scalpel below the ligatures. One small artery Med, hut 9
jily checked. The remains of the tumour sloughed off in the course
of a few days, and the wound healed speedily.
Fkr. ::.
In the last three cases the production of the tumours may, without
doubt, be attributed to a syphilitic taint in the system.
Reports of the Dublin Obstetrical Society 218
Cask V. — Hypertrophy of Nymphacmd Prepuce. The subject of this
otBe was ■ young lady, aged 20, of healthy constitution, and menstruating
regularly. For some month* she observed a gradual enlargement of 1 1 j + -
labia minora — at times more remarkable — especially alter exercise, or ;it
the catamenial epoch. Cm these occasions she obtained relief by punc-
turing the tamoors with a fine noodle, thns grring <\it to some watery
fluid. 'Tli*- left aympha was enlarged to the size of a Spanish chestnut,
and so was the piwputium elitoridis; the righl aympha waa elongated
and thickened. All these parts were Dearly of the natural colour, of firm
texture, and free from pain. The surface was rough, but not fissured or
tuberculated. The social position and moral character of thin young
woman, and the physical condition of the genital organs, all concurred to
justify the opinion that .-he was perfectly chaste, and not addicted to any
improper practice. For the space of two months various local and
general mean- were employed, but without the effect of producing any
diminution in the size of the tumours. She was then seen, in consultation,
by Dr. Stewart (of Lucan), Mr. Cusack, Dr. Denham, and Dr. M'C, all
of whom agreed that extirpation was the only mode of cure. Accordingly,
on the following day, she was put fully under the influence of chloroform,
and Dr. M'C. removed the diseased parts with the ecraseur, by two
operations. She was placed on her back, and she struggled a good deal
during the operations, which both lasted 45 minutes. When she had
recovered from the influence of the chloroform she complained of very
severe pain in the vulva. This continued for some hours. The healing
of the wound was very tedious ; but the result of the operation was highly
satisfactory ; and she continues well to the present time, and without any
reappearance of the disease.
In this case the appearance of the tumour differed in one respect from
that of the three previous ones, namely, that, whereas it was only rough
on the surface, they were deeply fissured and tuberculated. Dr. M'C.
suggested that perhaps this difference might serve as a diagnostic mark
between syphilitic and other tumours of the nymphae, as there was no
shadow of ground for suspecting any syphilitic taint in this patient, whilst
there was clear evidence of the other three women having had constitutional
syphilis.
lee of Malignant Disease of the External Genitals formed the next
group brought before the meeting.
n VI. — A. F., aged 61, had seven children, but, when admitted to
the chronic ward of the Lying-in Hospital, was a widow for 12 70818.
Menstruation had ceased for two years; and some months before her
admission into hospital she had QOticed a hard kernel in one nympha, and
had frequent pruritus of the part This tumour had gradually enlarged
>\ [
the Dublin 0 tty.
and ulcerated, involving adjai ent parts. 1 he seat <<t this ulceration \\ as
bard, and patches <<t the surface had ;t black melanotic colour,
which ii .1 rare accompaniment of hard canci I ■ nallysomc bloody
discharge occurred, and severe darting pain ivai at times experiem
The i and uterus a irtained to be healthy, [ndurated and
enls cisted in each inguinal region. The chloride of zinc,
and the dried sulphate of sine ivere at different times applied to the
diseased part, and the former caused a considerable slough to be thrown
off. A \ ast amount of pain, and no benefit, resulted from these applications.
\ 11. --Was a woman, aged oi*>, who for 18 months was ann
with pruritus of the pudenda; then a tumour made its appearance ; bu
months after which she came under the care of Dr. M'C. l*he clitoris
was greatly enlarged, indurated, and partially ulcerated. The swelling
extended around the right side of the ostium vaginas, forming a livid
coloured tumour in this situation. Though attended with some difficulty,
a careful digital examination of the uterus W8S made, ami it presented
no Bign of disease. The case was apparently one of cancer of the
pudendum, and in too advanced a Btage to think of any operation being
undertaken. The accompanying cut (Fig. 4) gives as good an idea of
the morbid appearances as can be conveyed without the aid of colours,
Fte. 4.
Case VIII. — Was a woman, aged G7 years, the mother of 10 children.
The entire perineum, mons veneris, and right labium presented one con-
Reports of the Dublin Obstetrical Society.
2 1 5
Millions surface of ulcerated epithelial cancer. Tubercles of the, same
disease bad formed in each groin, and were beginning t<> ulcerate. She
stated thai the complaint had appeared ahout a war previously, and that
it was not attended with mueh pain at any period. She had a .-cn-ation
of heat in the affected parts, and occasional difficulty in micturition, A
few slight attacks of hemorrhage had taken place. The disease had
began in the righl groin, and thence extended to righl labium. The
Vagina and uterus were found to lie free from every tangible sign of the
disease. This woman BUTvived tor 12 months longer. The woodcut
(Fig. •"») gives a correct representation of the size, extent, and granular
appearance of this malignant tumour.
Fig. 5.
The three cases just related were examples of carcinomatous disease of
the external genitals; and yet it is worthy of remark, that in no one of
them was there any indication of the uterus being similarly affected,
though in each a careful examination was made for the purpose of
determining this very point.
The last group of cases brought forward by Dr. M'C. embraced four
cases of Tumours growing from the Vagina.
1 16 Dublin ( '
IV ,' Tumour growing from \ I ttirpation. \
health} unmarried woman, about 30, admitted into the I o Hospi
July, 1845 ; 1»» monthi previously she began to actios b imall tumour in
the vagina, that 1ms been slowly bat steadily in< It
alw ;t\ a kept wiiliin the v ulva till the last two months, daring irhich unit- it
iiiti I been generally external, and always so when she was up andexerti
elf. On examination tin- growth was found protruding, and resembled
much in size ami appearance the procident womb. The subjoined wood-
cut (from a drawing by the late- .Mr. Neilan) shows the position and bulk
of this tumour* (Fig. (*.). It Bprang from tin- lower part of tin- antea
wall of the vagina, extending down to within a few lines of tie- meatus
urinarius. It had no connexion with the interior of the bladder or
urethra. In structure it was very firm, and admitted of very little dis-
placement. It was two inches in length, and upwards of four inches in
circumference, and had nearly the same thickness from base to ap
ween the tumour and cer\ ix uteri the intervening portion of vagina
was healthy. The investing membrane of this tumour resembled that
of the vagina, except towards its extremity, where there existed some
superficial ulceration. It had given rise t<> no other annoyance than
what resulted from its bulk and situation. She menstruated regularly,
ami had full control over the bladder.
Being satisfied that the bladder was not implicated in the formation of
this tumour, it was determined to attempt its removal by the ligature.
Dr. Johnson (then master of the hospital) and Dr. M'ClintoCK tightly
encircled its base, keeping clear of the urethra, with a ligature of silk
fishing line, confining it by means of Levret's canula. On the third day
the discharge was fetid, and the ligature had formed a deep indentation
all round. The ligature was tightened from day to day. On the sixth
day the entire tumour was in a state of slough; a transverse burst Of
rupture had taken place in its right side, from which a good deal of blood
had Bowed during the night. The pulse was rapid, ami she seemed low
and weak to day. On the 11th day the canula and ligature were removed,
and as much of the slough excised as could be conveniently reached.
By cutting away a part of the slough from day to day the whole was
removed before long, and the occasional use of the warm bath, with
unremitting attention to cleanliness, subdued all the swelling and inflam-
mation of the labia. A very minute examination, three weeks after the
detachment of the ligature, could not detect any remaining portion of the
growth. A slight incontinence of urine existed, but this became daily
less troublesome, and in a few weeks altogether ceased. This woman was
seen, some months after leaving the hospital, and she continued perfectly
well, and without any return of her complaint.
a The woodcuts illustrating this report are from engravings by Mr. Oldham.
Reports of the Dublin Obstetrical Society. 217
This growth was extremely firm and unyielding, so much bo as to
justify the opinion of its being of a dense sarcomatous or fibrous nature.
After its vitality had been destroyed it appeared just like sloughing
tendon, so strongly marked was its fibrous structure.
Fig. 6.
Case X. — Fibrous Polypus of Vagina; Extirpation. A tall, healthy
young woman, aged 23, in the seventh month of her first pregnancy,
suddenly felt something to prolapse from the vulva, whilst she was in the
act of running. This caused her much pain and uneasiness, and com-
pelled her to seek advice. A firm fleshy tumour, of a deep red colour,
was found protruding beyond the ostium vaginae, but attached to the
posterior wall of this canal, and about midway up, by means of a flat
pedicle. This tumour was considerably larger than a hen's egg, did not
bleed when handled, and was not painful to the touch ; and the patient
affirmed that she had been wholly ignorant of its existence till the present
time. Without much trouble it was returned into the vagina, and it
slipped into the pouch or depression ordinarily existing in the posterior
wall, but which, in this present instance, was much enlarged. This gave
her much ease ; but the tumour prolapsed again. Deeming it advisable
thai this polypus should be extirpated as soon as possible, in consideration
of the woman's advanced state of pregnancy (for it might have seriously
interfered with parturition), she was removed into one of the chronic
wards of the Lying-in Hospital, when Dr. Shekleton (then Master of
the hospital) applied a ligature to the pedicle.
On the fourth day there was a good deal of vaginal soreness, and some
t/i.- Dublin < Obat I
fetid d ■* Miiull portion of the pedicle iraj uncut, this
•rasdh ided with a scissors, and the tumour removed. She left 1 1**- boapita]
afterwards perfectly well. At the full I ihc
returned to the hospital in labour, which proceeded moal favourably, and
the woman made an excellent recovery.
This was a true polypus, and resembled, in its negative symptoms, the
last related — having given rise to no inconvenience what
ept the mere local annoyance produced by its bulk and accidental
displacement!
Cask XX — Fibrous Polypus of Vagina; Ecrasement. A woman, .
"J 1, in the last month of her second pregnancy, was received into one of
the chronic wards of the hospital, i»n the 5th July, 1<S.")7, with a tumour
at the vulva, and just beyond the vaginal orifice, the size of a small b<
egg, and of a deep livid colour. Dr. Geo. Montgomery, then an assistant
in the hospital, examined her, and found this tumour to be connected by
a stalk, with the posterior wall of the vagina. Dr. M*C did not see her
for three days afterwards. The external tumour had then disappeared,
but the growth was found lying in the tipper and back part of the \agina;
and with little difficulty, or pain to her, it was brought down into view.
There was BOme fetid, bloody discharge, which did not come on till after
her admission. The tumour was now considerably reduced in bulk,
softened, and of a black colour ; in fact it appeared partially dead and
decomposed, from the constriction exercised upon it, when protruding,
by the sphincter vagina. This tumour first appeared on the afternoon of
the 4th (the day before her reception into the hospital) and till then she
was wholly unconscious of the presence of anything of the kind.
Thinking it desirable that this sloughy mass should be got rid of as
quickly as possible, her labour being so near, Dr. M'C. put her under
chloroform, on the 9th, drew down the tumour, and safely excised what re-
mained of it with the eeraseur. In three days she was up, and the discharge
had nearly ceased. She went home; but returned on the 16th, supposing
that her labour had come on. True labour did not set in, however, till
the 20th, when she was delivered of twins. From the time of delivery
she began to sink, and expired in 34 hours afterwards. The cause of
death was not very apparent ; no peritonitis or traces of pus. The uterus,
however, was very large, and its interior was dark coloured and very
fetid— almost gangrenous. The only vestige of the polypus was a super-
ficial ulceration, the size of a sixpenny, low down on the posterior wall of
the vagina.
Case XII. — Cystic Polypus of Vagina; Puncture. A healthy woman, aged
23, was admitted, in labour of her second child, January 23, 1861. On
examining her vaginam, an oblong body was found attached to the back
Reports of the Dublin Obstetrical Society. 219
wall of tin' canal, within an inch or two of the Ofl uteri. This tumour
was fully an inch and a half long, rounded, and as thick as a man's index
flnger. It contained fluid, wss connected by a -mall pedicle, and could
be brought down partially beyond the vulva, so as to he rendered visible.
The Wall of the Cyst was of a whitish colour, and evidently very thin.
Ajb it was plain this tumour could not interfere with parturition it was
let alone for the present. Her Labour was easy, and her recovery good.
On her ninth day, and before leaving the hospital, Dr. M'C. examined
her again, and found the tumour in the same state as before. On punc-
turing it with a sharp pointed bistoury some transparent gelatinous
fluid escaped, and the cyst immediately collapsed. The puncture caused
her some lit lie pain. This tumour had given rise to no symptom, and the
woman was wholly unaware of its presence till it was discovered by Dr.
Halahan during her labour.
Of the four cases last related, three were of a well marked pediculated
form, and grew from the posterior wall of the vagina. The growth of
these tumours was imperceptible, and wholly unattended by any symptoms;
and their presence was discovered by mere accident. In the other case
the tumour had not a distinct pedicle or neck, but it possessed a strikingly
fibrous character. Its seat was the anterior wall of the vagina, so low
down as to approach the meatus urinarius. In fact the situation of this
tumour was the same as that of the growth described by Sir C. M.
Clarke, under the name of " thickening of the urethra," but it bore no
other resemblance to it whatsoever.
Dr. John A. Byrne read the following case of Rupture of the Uterus, in
which recovery took place.
M. A. Butler, aged 40, was admitted into No. 8 ward on the night of
September 12, 1860, about 10 o'clock p.m., in labour of her fourth child.
On making my nightly visit to the ward, at 11 p.m., I saw her, as well
as the other patients who had been admitted since the evening visit, and I
examined her. I found the os uteri soft and dilatable, not distended, the
head presenting, the membranes had been ruptured for a few hours before
admission, but she had scarcely any labour pains, and, in fact, she could
not as yet be said to be in labour. The fetal heart was very distinctly
heard in the pubic and right iliac regions and, to all appearances she was
progressing very favourably.
At about 7 o'clock a.m., on the following morning, the nurse of the ward
came to me, and requested that I might see her, being desired to do so by
the gentleman on duty. I visited her accordingly, and, on making
inquiries, 1 was told, that the pains had ceased for some time, and that she
had just vomited something, which, on examination, appeared to be fluid
which she had been drinking.
/i\ / tlir DubllTl ( >
I ii. .u made a wiv careful examination, and found that the head had
icended, but could not !>*• -aid to be irell in the pelvic «;t % its
presenting put t<.<», \iz. : the anterior fontanelle, was felt behind the
pubis, it W ft, ami elastic to llu- touch, ami tin- bonei ot tint
Ip wire loo>rl\ separated. The head, in tact, presented in a well
marked d igns of hydrocephalus.
The pelvis seemed sufficiently roomy, there irai no deformity, no
tumour, tin- sacro-vertebral promontory was not rery distinet,and ei idently,
the dystochia was tin- result of cephalic, not pelvic, disproportion.
There was a slight discharge of blood from tin- vagina, hut not to any
at.
I next proceeded to examine for tin- sounds of tin- fetal heart. Ami
after a most careful examination in which, subsequently, Dr. M'llintock
and Dr. Halahan took part, not the most remote trace of either it or the
bruit placentaire could he detected, although a few hours before they had
been heard very distinctly.
Her genera] condition was sufficiently alarming, her fact' had an
exceedingly painful and anxious expression, her lips were pale and clammy,
she moaned and complained of extreme pain over the whole abdominal
region; and this pain was increased by every attempt made to examine
the uterus ; she cried out not to touch her upon any account, the abdomen
was very tympanitic at the upper part, hut no symptom of extravasation of
the uterine contents existed. She also complained of a symptom which
is not usually noticed in descriptions of this accident, but which I have
remarked to have existed in some of the cases wdiich I have seen, viz. : a
Spasmodic pain passing through the upper part of the sternum and back
to the spine. Her pulse was small and thready; she had at first vomited all
the contents of the stomach, and, subsequently, a dark coloured fluid; and,
in addition, there was complete absence of uterine action.
On making inquiries, I ascertained that all her pre\ LOUS labours, three in
number, had been easy. She had had three children at the full time, but
had aborted, at the third month in her last pregnancy ; her general health
had been tolerably good, although she was much exposed to hardship,
being obliged to attend to a small apple stand in the open street. She
was a woman of middle size, had a hard withered look, but presented no
appearance of any deformity.
Now, taking a most careful survey of all the symptoms which presented
themselves, 1 came to the conclusion that the case before us was one of
rupture of the uterus, and that immediate delivery should be effected. In
this view Dr. M'Clintock, the master of the hospital, concurred. He, as
I have mentioned already, and Dr. Halahan, made a most careful exami-
nation for the sounds of the fetal heart, but they could not be heard in
any part of the abdomen.
I proceeded accordingly, assisted by them, to deliver her, by the opera-
Reports of the Dublin Obstetrical Society. '2'2\
tion of craniotomy. On the introduction of the scissors, about one half-
pint of serum came from ili«' cavity of the cranium: this having flowed
out, the remainder of the delivery was accomplished rapidly. No blood
flowed from the Petal skull, and the placenta was expelled immediately
alter tin- child, which was 8 male, of about ihe average size, very will
developed, and noi malformed, with the exception of the enlargement of
the head.
Some brandy was administered, and two grains of solid opium, with
one of capsicum, in a pill; and a sinapism placed over the epigastrium,
and the opium was ordered to be repeated in grain doses every hour.
Sept. 18, 4 o'clock, p.m., 7 J hours after delivery. — Vomiting still
continues; some reaction has taken place; she complains of great pain
over the uterus; eighteen leeches were ordered to be applied.
At 7 J o'clock, r.M., 12 hours after operation. — Pulse 120, small; the
opium pills were ordered to be stopped, and one half grain of calomel
and one half grain of opium to be given every hour.
Sept. 14, 2G hours after delivery. — Pulse 120, small and hard; she
was very uneasy during the night ; the stomach had been very sick, and
still continues to be so ; she can bear pressure over the uterus better than
yesterday; expression of face very anxious ; ordered to continue pills;
12 leeches to the uterine region; a sinapism to the epigastrium ; seltzer
water to drink.
Evening. — Condition very much the same ; the pills to be given every
three hours.
Sept. 15, third day. — Pulse 98; slept a little during the night;
uterus extremely tender ; considerable tumefaction of the abdomen ;
sickness still continues ; she was ordered muriate of morphia, calomel,
capsicum, of each £ grain, in pill, every second hour ; a sinapism to the
epigastrium, and ice to be placed in the mouth.
Evening visit. — Pulse 104, small and hard ; the bowrels moved too
often ; she was ordered to omit the pills, and 1 scruple of mercurial
ointment to be rubbed in, night and morning.
Sept. 16, fourth day. — Pulse 102; characters the same; did not
sleep well ; dozed occasionally ; but on account of the bowels she w^as
very uneasy during the night. She had had an anodyne enema, which,
to some extent, relieved her. A large linseed poultice was ordered to
the abdomen, and it to be smeared with mercurial ointment.
Evening visit. — Pulse 108; very feeble; there is great thirst; has
distressing hiccough ; she was ordered to have dilute hydrocyanic acid
2 minims ; Batley's sedative liquor, 15 minims, three times during the
night, and to have 3 ounces of wine, and the poultice and mercurial
ointment to be continued.
Sept. 17, fifth day. — Pulse 94; slept a little during the night;
complains of great thirst ; vomiting somewhat relieved ; still a great
the Dubh
1 of tenderness and hardness of abdomen ; di
ordered t" continue poultice and draughts ; chicken broth.
I I'-r,. — She had a rigor; pulse 96 ; to continue trine and
draughts.
Sept. 18, sixth day. — Pulse 94; paused a restless night ; romiting still
continue*; abdomen tender; ordered a sinapism t«> the epigastrium ; 15
grains of mercurial ointment at night and morning.
Evening. — Pulse 108; condition rery distressing; romiting during
the daj ; rery 1<>\\ ; ordered brandy 8 ounces; a blister to abdomen;
morphia \ grain; and dried Boda, 2 grains.
Sept. 19, seventh day. — Pulse L12; slept a little; romiting somewhat
relieved; mouth not affected yet; abdomen tumid and tympanitic; is rery
cheerful; thinks that she will recover; ordered mercurial ointment to
the blistered surface; brandy 4 ounces; t<» continue pills; to have sell
water; and to take 2 grains of Bulphate of quinine in mixture o times in
the day.
Sept. 20, 8th day. — Pulse 110; some sleep during the night; does
not complain of much sickness to-day; month not touched: considerable
abdominal tumefaction still; blister w\\ sore and gives her great pain
and annoyance.
Evening, at 6J. — She had a rigor. Continue pills, and to have four
ounces of brandy.
Sept. 21, 9th day. — Pulse HC; not much change; did not sleep much
during the night ; complains of very great weakness ; ordered brandy,
three ounces, and the mixture containing quinine.
Evening. — To have the same amount of brandy, and one half grain of
morphia.
Sept. 22, 10th dav. — Pulse 110; condition much the same; had some
sleep ; has distressing hiccough ; ordered to continue the brandy ; to have
the morphia at night, and chicken broth.
Sept. 23, 11th day. — Pulse 1<»,S; IS cheerful; her back is red and
tender; dislikes the brandy; to have wine, four ounces, and the same
complement of wine at night, and the morphia.
Sept. 24, 12th day. — Pulse 108, small; had some sleep ; her tongue is
sore from some ulcerations; a purulent discharge observed coming from the
vagina; ordered to use gargles, wine, and nourishment; vagina to be
SJ ringed.
Sept. 25, 13th day.— The vaginal discharge \ cry offensive ; mouth very
sore; considerable diarrhoea; continue wine, &C ; ordered — opium, one
half grain; ipecacuanha, one half grain; nitrate of potash, four grains;
three times a day.
Sept. 26, 14th day. — Pulse 101; mouth still very sore; ulcers to be
touched with solution of nitrate of silver; continue medicines and wine, cv.c
Sept. 28, 16th day. — Pulse falling, 92 ; she is improving gradually;
Reports of ths Dublin ohstrtn'ml Swifty. 223
there is still, however, some diarrhoea, for which Bhe was ordered suitable
treatmenl ; offensive vaginal discharge still continues.
Sept 80, L8th day.— Pulse 92; progressing favourably; no symptoms
indicating danger; surface of abdomen healing; the abdomen is soft,
and not painful, with the exception of the lower part, where there is -till
some pain fell <>n pressure; the leech-bites, however, are very sore and
painful; Bhe sleeps, and is able to take nourishment; is very cheerful;
she still, however, suffers from occasional diarrhoea, which continued at
intervals, until
Oct. 4, 21st <lay, when she presented the following signs:— Her
pulse was 92 — of a better tone, however; she sleeps tolerably well ; dis-
charge from vagina not so offensive; diarrhoea greatly checked ; some
pain, on pressure still, over lower part of uterus; is exceedingly cheerful ;
has sonic appetite. She went on in this manner, with varying diarrhoea,
controlled by medicines, until
Oct 14, 31st day, when her pulse had fallen to 84; and the only
annoying symptoms which remained were the ulcerated condition of
the mouth and the diarrhoea, which gradually improved. She was allowed
to sit up at the fire in her ward; her appetite began to return; and in
fact she was pronounced out of danger ; and on
Oct. 27 — 37 days after her admission — she left the hospital quite well,
some weakness, however, still remaining.
On the day before her departure we examined the vagina and uterus
with the speculum, and we observed what appeared like a ridge of granu-
lations across and through the os uteri. It had the appearance, in fact,
as if a portion of the right wall of the vagina had been united to the
middle of the cervix uteri. On touching this ridge it bled freely, and pus
exuded from the line of junction ; and, on looking at this, we had not the
slightest doubt upon our minds that we were looking upon the new struc-
ture which filled up the rent, and we were quite satisfied that it was in
this situation that the rent or fissure had taken place.
In about three months afterwards I met this poor woman near my own
residence, and she addressed me, and asked me did I remember her. I
asked her to call upon me; which she accordingly did; and she then
informed me, that since she left the hospital she had enjoyed very good
health, with the exception of not having menstruated, until about three
weeks before I saw her. Before the menstrual discharge she felt what
she compared to a heeling in her side ; and this was followed by the dis-
charge of a thin bloody fluid, resembling, as she said, wine and water.
This continued about the usual time of the menstrual flux, and then
disappeared. She promised to return to me at some future time, to be
examined, but she did not; so that I am unable to give any further
history of her case at present.
I musl apologise for having entered so fully into the details of this
Dull
; but it happened to (»«• one of those in which details b tment,
,1 \ . Such a • wpen at anj mora
in practice ; and t! oner in which
thi> patient was so unexpectedl) affected by this oomplic ition of labour —
then rallied from collapse seemingly fatal — then became affected with
reactionary symptoms, which became so aggravated as to menace dis
lution ; but which, bj means of the treatmenl employed, gradually yield
and were finally subdued, and afforded to us the pleasing gratification of
ing a favourable termination t* » an accident which is most properly
considered as one of the greatest calamities thai can befall a parturient
woman — will not, 1 hope, be deemed unimportant.
The objection might, possibly, be urged i»\ Borne persons that the array
symptoms which I have given was not sufficiently clear to induce us to
pronounce this positively a case of rupture of the uterus. We Bee that
many of the Bymptoms of this accident, as laid down by author-:, were
absent ; as for instance, hemorrhage — recession of the presenting part —
the absence of any sensation, on the pari of the patient herself, of the
accident having occurred — the absence of any part of the body of the
child in the abdoininal cavity of the mother. Now, no doubt these symp-
toms were absenl ; and our diagnosis Mas founded upon the presence of
the remaining symptoms — such as the extreme eollapw — collapse which,
I believe, is peculiarly indicative of this accident — upon the agonised look,
which, tO one accustomed to see cases of this kind, almost always prompts
him to examine for the remaining symptoms which are pointed out by
authors as pathognomonic of rupture — upon the abrupt cessation of the
labour pains — but founded, above all, upon that symptom which is
peculiarly indicative of it — particularly when combined with other Bigns —
I mean the cessation of the fetal heart-sounds, a symptom which has
been so strongly dwelt upon by Dr. M'ClintOck in his paper upon this
Subject — and founded also upon the manifest fact of an existing dispro-
portion between the head of the child and the osseous | - of the mother.
Now, taking all these circumstances into consideration, it will be
admitted, 1 think, that our diagnosis of this case was correct, and that
we were quite justified in regarding it as one of rupture or laceration of
some part of the uterus ; of what part it mattered little as to practice.
our treatmenl was at once indicated, and was quickly carried out.
As authors inform us we must not expect, in every case of rupture
of the uterus, to meet the same identical symptoms. In some the majority
of the signs will be present, and some few may be absent ; and again, in
other cases, the latter may be present, and the former may not; so that
it is well that we should be prepared for this, and not hesitate about what
is to be done, because we are not satisfied on account of the absence of
one or more signs. The ease is one which leaves no time for indecision,
and our remedy must be prompt.
Reports of the Dublin Obstetrical Society. 225
Notwithstanding all thai lias been written upon this subject, and all the
statistics which hays been !_ri\ en \\ iih regard to the comparative frequency
of this accident in primipara and multipara, we generally find that it is
an accidenl which occurs ■with greater frequency in those who have had
children.
If we add tO the 75 cases collected by Dr. Churchill those, related hy
Drs, Sinclair, and Johnson, and Eardy, and M'Clintock, and this, the total
18 I02j and OUl of this number rupture of the litems occurred in hut 10
primiparsa, or in aboul one-tenth of the whole; and out of Dr. Trask's
collection of 808, it occurred in but 24 prinripara, or something more than
one-twelfth of the whole. So that we observe that there is a very elo.se
approximation in the results arrived at by these observers.
The history of those cases tells us that no age is exempt from the
occurrence of this accident — the young, the middle-aged, and those more
advanced in years are all subject to it — but not equally so. Those about
the middle age are most subject to it, according to the tables of Dr.
Collins. Thus, out of 34 cases, 19 occurred between the ages of 29 and
37, exclusive of those two ages, in a range of years between 16 and
40. Now, excluding accidents, excessive uterine action, narrowing of the
pelvis, or disproportion of any kind, we may, I think, with tolerable
certainty, account for the greater frequency of it, at or about this period,
by the change which the uterine tissue undergoes either by fatty degenera-
tion or ramollissement — the post mortem examination generally revealing
some such change in the part of the uterus where the laceration has taken
place.
Although excessive uterine action may per se produce laceration of the
uterus, yet, as this and many other cases recorded by authors exemplify,
we see that rupture is very often found where there has been very little
uterine action. How seldom do we find the uterus to rupture in primi-
para^, where the action is strong, and where there are many obstacles to
overcome ; how often have we to introduce the hand to turn or remove
the placenta without injury being done to the uterus ; how often, too, in
cases of disproportion we see the uterus acting powerfully and for a long
time, and yet this accident does not occur ; but in the case which I have
related at no time was there strong uterine action, or at least what was
sufficient to produce this injury, if, perhaps, she had not to the enlarged
head of the fetus also had, superadded, a softened or thinned cervix uteri.
These two causes combined, I have scarcely a doubt, were conducive to the
occurrence of rupture in this case.
Hydrocephalus is generally laid down as one of the causes which may
produce, or rather conduce to this accident ; yet in neither of the reports
which have lately emanated from the Rotundo Hospital is there a casein
which it could be attributed to hydrocephalus; although Murphy, Lee
Collins, Ramsbotham, and others relate some cases, it is not at all iin-
vul. xxxm.. no. 65, x 8. Q
Dul ' ety,
tsible ih a the child in thu lid hare passed Ihrough the pelvii
j not b case of enormous hydrocephalic enl at; the fluid contait
did not amount t<» one pint; the head iras partly down in the peli
and, ia my mind, there was scarcely a doubt that if tin- pelvis w-
ciently roomy — as ire had no reason to suppose prai not the eeet —
and if the action of the uterus bad been strong, and tin- of the
uterus healthy, the child might have passed through alive. We know
that many cases arc on record of children with larger heads than this
having passed through a properly formed pelvis. Bierriman mentionj
a ease in which the circumference of a hydrocephalic head measured,
after being born alive, 'i'l inches. Now in this Case which I have detailed
there was Scarcely any uterine action at all; and the uterus, it IS highly
probable, gave way, perhaps, under the influence of a feeble pain, which,
acting in conjunction with too large a head, and too soft a uterus, pro-
duced the laceration.
With regard to the recovery of patients from this accident, the tables
on this head are not very encouraging; taking the number of CS
recorded by Dr. Churchill, which amount to 80 — and adding those related
by Drs. Sinclair and Johnson, 17 — this case 1 ; total, 98 — we have only
11 recoveries, or a little less than 1 in 9.
Now this is confessedly a very small number of recoveries; but still
the result is one that should lead us to have hope, and to trust in the
recuperative powers of nature, even in such a formidable complication of
labour as ruptured uterus. We know how to treat this accident better
now than formerly. We know the beneficial effects of large doses of
opium, and the advantages of the non-depleting method of treatment;
ami had we even on record no other case, as a proof of the efforts of
nature to effect a cure, the wonderful case so ably recorded by Dr.
Mackeever, in which, in addition to the rent in the uterus itself, there
was also a sloughing of a considerable portion of the intestinal canal, and
in which the patient survived, and afterwards became pregnant, would
induce us to not despair of a successful termination to this formidable
accident.
The occurrence of rigors on the fifth and eighth days, respectively,
is matter well deserving our attention. We know that this is in general
a symptom denoting the occurrence of pus formation ; and it is scarcely
presuming too much to attribute, in this case, the rigors to such a circum-
stance, particularly when we remember that they were succeeded by the
escape of matter from the vagina, which continued for a considerable
time ; and the seat of this escape of matter was afterwards, on the
recovery of the patient, manifested in a well-marked manner. If this
were true, it is a beautiful illustration of the manner in which it may be
supposed that nature effects a cure in such cases. Firstly, we had in-
flammation, peritonitis, effusion of fibrin, formation of a pus-secreting
Transactions of the Cork Medical and Suraiail Sorictij. -j'27
surface, and tin* entire mass of the Btructures engaged well guarded by
the fibrin poured out around them; and, in fact, the whole mass might
be said (<> resemble the cysl of an aba
Db, BLlcSwinei exhibited the aterui of an onmarried woman, aged
58, which bad an oblong tumour, fully the use of the uterus itself, attached
by a rather narrow, and very short pedicle to the fundus of the organ.
The patient, from whose body it bad been taken, bad recently died under
Dr. MaeS.'s care, in .It Tvis-shvct Hospital, from a very -everc attack of
acute desquamative uephritis, after an illness of only about fourteen days.
When detailing the history of her illness, she said that she had enjoyed
excellent health all through life — ne\er having been in the least ill until
seized with the malady under which she laboured when she came into
hospital. She had never experienced any inconvenience or distress from
the a fleet ion of the womb. It was first detected when the post mortem
inspection of the body, with a view to ascertain the condition of the
kidneys and other parts, was being performed. The uterus was of the
normal size of the virgin organ, and healthy. The tumour, situated as
above described, was about 2-| inches long, 1 J inch broad, and 1 inch
thick. It was nodulated, and of a whitish-brown colour. It felt hard,
and weighed heavy. Upon making a section into its interior the edge of
the scalpel was turned upon a considerable amount of hard substance with
which it came in contact, and which was very difficult to divide. In fact
ossific degeneration had proceeded to a considerable extent in the struc-
ture within the tumour.
TRANSACTIONS OF THE COUNTY AND CITY OF CORK
MEDICAL AND SURGICAL SOCIETY.*
( Continued from vol. xxxii. p. 222.,)
SESSION 1861-1862.
Opening Meeting, October 9, 1861.
ANNUAL ADDRESS
By John Popham, A.M., M.B., Licentiate of the King and Queen's
College of Physicians ; Physician to the North Infirmary and Union
Workhouse, &c, &c, President of the Society.
In seeking for a subject upon which I may address the members of the
Cork Medical Society at their opening meeting, it occurred to me that
a brief retrospect of its foundation and progress may not be unacceptable
* These Reports are supplied by Dr. W. P. Bernard, Secretary to the Society.
Q 2
/ / m ictiom of the <
our junior brethren. Am 1 happen to be twyuig the i>-w uriginal
members now remaining — & lift, comprising Dre. II Bullen, Finn,
Connor, Tanner, Hobart, dkc — who "rocked the cradle of ii§ infancy,"
I may, perhaps, be permitted to speak of it, in common with them, with
feelings somewhat akin to parental partiality.
The Cork Medical Society owed its beginning to the medical
the city hospital^. The late inspector-general of the forces m Ireland,
Sir James Pitcairn, consnlting surgeon to the South Infirmary , abn
anxious to promote a spirit of harmony amongst the members of our
profession, proposed to the medical officers of the innrmaries to meal
month about at each Others' houses ; ami after an innocent participation
of the festive comforts, to terminate the evening in consulting together
upon those difficult eases occurring to each other, which may require
elucidation from united experience and skill. At one of those pleasant
reunions — those " nodes ccmaque (hunt' — it was resolved that we should
extend more widely the advantages of our little medical conference, by
Changing its peripatetic character, and a plan, founded on the rule- of
the several metropolitan medical societies was thrown into form by Dr.
Harvey, as secretary, and obtained favour with our local brethren. Since
then, with some necessary modifications, it has passed through a long and
honourable probation; and in Looking back we have but one regret — that
time has dealt hardly with us. The honoured nam.- of Pitcairn, Uull,
Howe, Lloyd, Haines are still fresh in our memories, which testify both
to our private Borrow and to the public loss which our profession, in this
city, has sustained.
Before the institution of the medical society, our city and county,
though alwavs abounding with excellent practical j > 1 1 \ -icians and surgeons,
can scarcely be said to have contributed hvyely to medical literature.
Some valuable publications and articles, by various Cork physicians, have
appeared at intervals since the commencement oi the present century;
and we can refer back to the works of Dr. Joseph Rogers in 1734, upon
the epidemics in our neighbourhood, and of Dr. Maurice O'Connell, in
1 7 16, giving an account of the praxis of Cork, but no continuous effort took
place till the selected papers of this society were published. In 1850 I
had, as secretary for that year, the gratifying privilege of preparing OUT first
Report for the Dublin Quarter/// Medical Journal. Our little offering was
received with favour, and since that time the proceedings of our society
have taken their place, with tilial respect, in that Journal, alongside the
riper experience and maturer knowledge of its distinguished precursor,
the Dublin Pathological Society.
" Dextne se parvus lulus
Implicuit, sequitnrque pat rem non passibus sequis."
What better example for its imitation could it desire ?
Medical and Surgical Society. 229
It Deeds but little argument to show thai it depends on learned societies
themselves irhether their transactions become of positive or negative
value. Swell societies, by an union of intellectual ability, and a division
of labour, can effect what individuals must fail t<» accomplish; but they
are subject to periodical fits of energy <>r depression. Indolence is a
K taking" disorder, but, happily, emulation may become equally con-
tagious. It is wonderful how much can be accomplished by a few
energetic minds. Like iron sharpening iron, they make other minds
keen. When unity of action can be reckoned on, all that is required
to produce valuable results is to give it a proper direction. Let me give
you an example how the efforts of many, directed towards a single object,
have been remarkably successful. At the outbreak of the famine fever
of IS 17 and 1818, circulars were issued from the Dublin Quarterly Medical
Journal to the practitioners throughout Ireland, requesting information
upon a number of well-selected topics, respecting the nature and extent
of the epidemic. " To this circular," we are told, " more than seventy
answers were received, being, in some cases, extensive reports, and in
others satisfactory replies of shorter extent." Now what were the results
of this inquiry ? The universality of this formidable epidemic was at
once established, there being but one district in Ireland, namely, Ros-
trevor, in which it had not more or less prevailed. By the co-operation
of so many trustworthy observers, a body of evidence has been collected
upon this particular fever which has rendered its natural history one of
the most complete in medical annals. Now, how could any single, un-
assisted physician, however accomplished, give an account so compre-
hensive as this ? He could only view the disease within a circle of a
narrow radius, and could speak but doubtingly upon the varying phases
which it must have presented when the disturbing influences of differ-
ences of situation, climate, geological condition, diet, and other circum-
stances altering the type of disease, were brought to bear upon it. In
order to form a fair opinion of the value of these reports, we have
only to compare their fulness with the meagre descriptions of epidemics
of fever previous to the present century.
I may quote another illustration to the same effect from the valuable
papers of Drs. Stokes and Cusack, upon the mortality of Irish medical
practitioners. We had, in the famine year, become painfully accustomed
to the mournful iteration of the ill-boding words — " died of fever, caught
in the discharge of his medical duties ;" but we did not know the fact,
until they discovered it by circulars sent to every corner of our island,
that in the year 1847, one-fifteenth of the whole medical community
was swept away, and that while the mortality from fever, compared with
deaths from all causes, was as 1 in 10 for the whole population, it was
as 1 in 2^- for medical men in Ireland. The mortality of Irish prac-
titioners was thus, by the efforts of individuals acting upon the whole
i ty and •
ion, pr< that of army . .n amidst all
tin- chances and privations of war.
[have brought before youth unples as irorth j of imitation \>y
ourselves. What is there to prevent thi ty, unless our
o sending out circulars of inquiries when any suitable object for
investigation occurs, and thus enlisting the experience and research
our c<»uuty or provincial brethren? We mutt not rest content with
>rding cases of ephemeral interest, but rtrike out boldly in quest
matter of more general and durable utility. WTrj is the Academic de
M. decine of Paris so trustfully consulted by the French government in
all cases of public health ? Is it not from the admirable reports which
it issues on all disputed questions of disease and hygiene? Whenever ■
new operation in surgery is proposed, a new medicine is to be tested, a new
sanitary scheme to be estimated, it appoints its commissions of inquiry.
Too large a body for conjoint action, it divides and subdivides its mem-
bers, telling off two, perhaps, for one question, three for another, and
always selecting those members whose special acquirements enable them
to probe the matter home, with science and skill. Why should not our
society, abounding with well-educated energetic young men, and a
Sprinkling of grey-headed seniors, have, alter such high examples,
our committees to test the claims of the useful or fashionable medical
theories of the day? There are now floating before the minds of the
public many interesting subjects of social science; many suggestions
about hospital reform and general therapeutics. If we do not take up
these questions of ourselves for discussion, we must be driven to do so
by the force of circumstances. Non-professional gentlemen, and what
is more tantalizing, e\ en non-professional ladies, are actually entering
the Lists against US, and are laying a kind of exclusive claim to the
department of public health. They are converts to the doctrine of fir
trade in physic, and there is this difference at least between us and them,
that if we are wisely sceptical about the success of a project, they evince
a happy dogmatism. If we sometimes judge without deciding, they
decide often without judging; and hence we find a number of crude
speculations fluttering about the public ears on questions which our
profession is accustomed to pronounce upon with some diffidence. I am far,
indeed, from condemning the well-intended exertions made by philan-
thropic ladies to reform our prisons and our workhouses, our factories
and our schools. I would not interfere in the least with their inspection
of the cook-house or laundry, or in the more important subject of
industrial education, but they go beyond their province when, as in the late
Social Science Meeting, they profess to prescribe for the sick. Why do I
dwell upon these topics? It is to urge upon my medical brethren that the art
of medicine is widening its circle, day by day, and that the public will
not be satisiied unless its medical officers thoroughly understand the
Medical a inl S/frainil Sod,///. 281
greal measures of sanitary improvement. And when such questions are
taken op with zeal by well-educated physicians, qualified to pronounce
upon them by a course of Btudy, the most extensive of any of the Learned
professions, the opinions which they <1<> pronounce shall be with a voice
of authority which no connnunity will he BO adventUTOUS as to think of
resisting.
There ifl bul one subject more upon which I wish to make a remark;
as it 1a much misunderstood by the public, who think that our profession
is a purely practical one, and that the study of books is vastly inferior
to that of nature tor Learning medicine. I would reply to this fallacy by
the words of the wisest observer of nature that ever lived ; "If a man,"
say- Bacon, "read little, he had need of much cunning to seem to know
that he doth not. Crafty men contemn studies, simple men admire them,
and wise men use them." They who profess to disregard study are
either obtuse or hypocritical, too dull to see their own ignorance, or too
cunning, as Bacon says, to let it be seen. What would each of us
become if denied access to the sages of medicine, and confined writhin the
narrow limits of our own genius? The chief improvements in medicine
have come not from what are called self-educated men, but from men of
philosophic minds, who have not merely read, but also digested. In one
sense only is this opinion correct. The active duties of the practitioner
lessen the time for study. With, howrever, all the drawbacks, whether
self-imposed or from the tyranny of circumstances, I believe that it is
true of the medical profession, that while it can point with honest pride
to many of its most enlightened members who branched off into the
flowery paths of natural and experimental science, it is, taken as a class,
amongst the best informed in the community.
Case of Aneurism of the Descending Thoracic Aorta, complicated ivith
Pericarditis and Pleuritic Effusion. By Dr. W. Peterson Bernard.
Michael Horgan, aged 22, unmarried, and of very intemperate habits,
a labourer, was admitted into the Workhouse Hospital, under the care of
Doctor William C. Townsend, on 9th October, 18 GO, suffering from
violent palpitation, on the least exertion, and pain in the left side of chest.
1\\< health he describes as excellent (being able, without fatigue, to
follow his laborious occupation), up to two years ago, when he was
attacked with intermittent fever, for which he was treated in this hospital
from time to time. When last admitted, in May, 1860, he complained of
weakness in the loins, and pain in left side. The chest was carefully
examined, and no disease detected ; the urine wras also tested for albumen,
but none was present. After a few days, during which he received
treatment more dietetic than medical, at his own request he left the
hospital, much relieved but not free from occasional pains. He now
yf the Count// and I I
srent to the neighbourhood oJ Blarney, where h,- pursued, without
inience, his usual evocations. His nearness to th<- rurkish bat
and IV i them, induced him to make use ol them, (entirely on
nil own responsibility and without medical advice), no I'— fivquently
than 11 times in u-n i frequently, during t!. ht,
lu turiating in two, daily. During tin- use ol the baths (and he iras firmly
maded that consequent on their use) the palpitation beeaim
persistent and distressing, followed in s few weeks by the fettd pain
in the chest, from which, up to the time ol his death, he eras never
entirely free, the lumbar pain attacking him occasionally as before.
State on admission, 'Jth October, 1800. — Body wasted, appearand
anemic, with a bilious tinge, countenance expressive ol anxiety, tongue
clean, secretions normal, eats and sleeps badly; decubitus entirely on left
side; pulse in the recumbent position, right wrist, 'J 2 and regular; no
pulse felt in left wrist, but about the middle third of the forearm it
becomes perceptible, beating at % and regular. The heart's impulse is
vers excessive, the heaving of the chest being perceptible when standing
some distance from the bed ; area of cardiac dulness much increased ;
respiratory sounds (dear, and no appearance of dyspnoea. He complains
of pain in left side of chest, hardly noticeable while he is still, but
becoming distressing on very little exertion.
To have of the tincture of muriate of iron, and tincture of digitalis, 10
minims three times a day, his diet to consist of bread, meat, and one pint
of porter.
October loth. — About midday yesterday, whilst walking about the
ward, felt the pain suddenly and completely leave the chest and attack,
with severity, the loin-, resuming its former position in about an hour.
1 1th. — Slept but little last night, because of the palpitation and pain
in the cardiac region ; distinct murmur heard with first sound of the
heart when he assumes the erect position, much less distinct when
recumbent. Heart's impulse perceptibly increased since last report.
Omit the tincture of iron, and continue the tincture of digitalis.
15th. — Had a good night, and looks more cheerful; palpitation and
pain much less ; murmur scarcely perceptible in any position ; pulse in
right wrist, 84, regular and firm.
[(Jth. — Slept well, and is almost free from pain, but cannot lie on the
right side even for a few minutes.
17th.— Had a tolerably easy night, decubitus same as at last report;
pulse 9o, regular; pain in precordial region entirely disappeared; cardiac
murmur with first sound very indistinct in recumbent position, dis-
appearing entirely when placed in a sitting posture, impulse very strong.
Continue tincture of digitalis, and the diet as before.
18th. — Feels much better than for several weeks past, and can now
lie on either side without the slightest inconvenience ; complains of the
Medical and Surgical Society. 233
weakness of tin* Loins, occasionally amounting to an aching pain; cardiac
murmur very distinct and rough when examined in the erect position;
not quite bo distinct when recumbent. Continue tincture <>f digitalis,
increasing cacli dose from 10 tO 1 5 minim-.
20th. — Heart's impulse enormously increased since last report; feels
palpitation more to mesial line; relishes his food, secretions fairly
carried on.
22nd. — Had a good night's rest, looks and feels better.
24th. — Complains of the palpitation, which prevented his getting much
sleep last uighl ; his spirits are, in consequence, very depressed ; pulse
96, and regular; impulse and murmur, both as aggravated as when last
reported. Continue digitalis, and to have a desert spoonful of cod liver
oil three times in the day, with the hope of checking the excessive
wasting which is going on.
26th. — Cannot lie on the left side, but had a good night, and is more
hopeful ; jugular pulsation very distinct.
30th. — Pulse, 84, feeble but regular; palpitation less distressing;
cardiac murmur not so distinct ; jugular pulsation more evident than at
last report. Continue cod liver oil and tincture of digitalis, the latter to
be reduced to 10 minims each dose.
November Gth. — seems stronger and improved in every respect.
A few days after last report, he was transferred to the South Infirmary,
being still under Dr. Townsend's care, and with the same line of
treatment continued. There he remained for about three weeks, and
then, feeling so much better, he went into the country, and was not again
under observation until September, 1861, when he was readmitted into
the Union Hospital.
1861, September 26th. — He states that during the many months he
was out of hospital, he was able to earn a livelihood by labouring work,
chiefly of a light character, such as whitewashing, &c. ; the pain in the
loins was not at any time very severe, though seldom entirely absent.
The palpitation had of late become very distressing, and after mounting a
high ladder, he had frequently, when he descended, to throw himself on
his face and hands for a few moments to relieve the palpitation and
attendant pain in the chest ; his appetite began to fail, and his strength
so perceptibly declined, that he was reluctantly compelled to give up a
life of freedom for the comparative restraint of an hospital.
His habits of late were temperate, rarely exceeding a pint or two of
porter in the day. His appearance is now very anemic, and muscles
greatly wasted, tongue clean, bowels acting fairly ; urine scanty and high
coloured, no albumen ; appetite very bad and stomach irritable ; com-
plains much of palpitation, and soreness over left side of chest, which is
found, on percussion, to be extensively dull, occupying not only the
cardiac region, but also the base of the left lung ; the sounds of the
m of t! < tij and ■ I orh
listinct l>ut feeble, with marked bruit; jugular reim of both
much distended, no pulsation at either wrist; there if no
1 or the past three or four weeks he can only li-- on bis back >>r
right sid
A mustard unapism t<> be applied over the cheti Ui^ di I to consist
of I- . wine and Boda-wat
September 27th. — Bad t bad night owing t«> the Mhes I the
chest," (the pain was wn much relieved by the sinapism) ; ha
for the first time from slight dyspnoea; pulse at tin- wrist i"'», and
extremely feeble ; the chest was not oaref nil y examined, as the attempt
med to give him paint
Tito sinapism to be repeated night and morning, and his nourishment
continued; to have, at his own request, two eggs at breakfast hour.
i. — Had an uneasy night, tie' respiration again free from embar-
rassment ; Left ride of chest prominent, evidently from increased effusion ;
impulse of heart feeble and entirely t<> right side, the apex beating
inferiorly and posteriorly to right nipple, no murmur perceptible; the
lumbar pain has become more aggravated, but is now entirely referred to
right lumbar region.
Mustard stupes to be applied to the loins, and his wine and beef-tea
continued.
30th. — Sinking rapidly ; increasing dulness, and absence of respiration
over entire of anterior and lateral portion of left lung, save at the
extreme portion of apex, where the respiration is puerile; posteriorly it is
clear on percussion, and the respiratory sounds normal.
October 1st. — Had a good night ; is quite free from pain and dyspnea*,
and seems rallied.
3rd. — Lumbar pains again last night, but this time complained of all
over the back, and not confined to any one spot.
Mustard stupes to be applied to back and loins, and his nourishment
continued.
4th. — Pain much relieved by the stuping, but he is extremely feeble ;
no pulse to be felt in either wrist, nor in the temporal arteries.
7th. — Still weaker than last report ; Lb again suffering slightly from
dyspnoea; extremities cold, the hot jars are constantly applied; no trace
of anasarca ; tip of nose quite black ; appears as if gangrene were setting
in ; he is free from pain.
8th. — Rapidly sinking ; decubitus entirely on right side ; black ap-
pearance of nose spreading considerably (involving fully a third) ; is now
undoubtedly gangrenous.
10th. — Died this morning; was free from suffering at the close, and
his intellect clear.
Post Mortem JExcunination. — When dividing the costal cartilages at left
side, serous fluid was found to well out, and on raising the sternum, the
Medical and Surgical Society. 235
left side of the thorax was found to contain a considerable quantity of
serum; the Long at the same side was collapsed, and lay against the
posterior wall of the thorax, where there were some slight pleuritic
adhesions; the pericardium was found very much distended, extending
into the right side of the thorax ; an opening was made accidentally into
the pericardium, through which the contained fluid escaped, (the fluid
Contained in the pleural cavity and pericardium, was found tO measure
over four pints) : the hearl and the cardiac surface of the pericardium,
were both coated over with a thick deposit of lymph, which presented a
peculiar granular appearance, both were highly congested; the mitral
valves had a slight deposit of lymph on their surfaces; the other valves
appeared healthy ; the left side of the heart was considerably thickened,
though the organ, as a whole, was but little increased in size ; the right
Lung was everywhere adherent to the costal pleura, the strength of the
adhesions, particularly posteriorly and inferiorly, making its removal a
matter of much difficulty.
On examining the thoracic viscera, a tumour, as large as a goose egg,
was found in the lower part of the posterior mediastinum, its inferior
edge reaching as low as the diaphragm ; this, on examination, proved to
be an aneurism of the descending thoracic aorta, though undetected
during life ; the most careful effort to remove the sack complete was
unsuccessful in consequence of its firm adhesion to the vertebrae. On
cutting into it, five of the vertebrae Avere found very much eroded,
appearing to constitute the posterior wall of the aneurismal sac ; a
quantity of coagulated blood was evacuated, and a large mass of fibrin
removed. The liver was found enlarged, and of the nutmeg character.
Remarks. — There is one subject in connexion with the foregoing case
which, I think, calls for a few observations. I refer to the strong
evidence, and very marked symptoms, of cardiac disease that existed
during life ; the remarkably augmented impulse, more than once alluded
to ; the increased extent of dulness, on percussion, in the cardiac region ;
and the well-marked bruit heard over the heart, (all which symptoms
became more marked as the case advanced), would, I conceive, have left
no doubt on the mind of any Physician that there existed hypertrophy
and valvular disease of that organ.
The situation of the aneurismal tumour, however, seems capable, in a
great measure, of explaining the cause of these symptoms, for, being
placed directly behind the heart, it would tilt that organ forward at each
pulsation ; and this distension, being synchronous with the heart's action,
would cause an increased impulse.
The increase of dulness may be explained by supposing the heart to be
pushed forward by the tumour into closer contact with the parietes of
the chest, and so displacing, to some extent, the overlapping lung ; the
bruit must, I conceive, have been conveyed through the heart from the
' 'v of ( ork
honour, ai the comparatively healthy condition of tin ►den it
emelj improbable that it could have originated in the I It.
One other point also demands ;i word or two. Hie patient bin
attributed the aggravation of hit Qlneai to the om of the Turkish bath;
and, under the luppoeition that the caee irae on< thisdid
not Mem improbable. During a recent debate in thii Society, it
argued that the Turkiah bath, by carrying off ■ large quantity of the
wratery portions of the blood, rendered it proportionable richer in fibrin ;
and that on this account it might inon see any tendency to the deposit of
lymph on the valves, m that the bath was considered dangerous for any
person labouring under cardiac disease ; and this case had been so
frequently spoken of as an illustration of the above theory, that I think
it only fair now to inquire whether the bath could have aggravated tin-
disease? and this, in a case of aneurism is, I conceive, not probable ; for
if the bath be dangerous in cardiac disease, by increasing tin- tendency to
fibrinous deposit, this very tendency (if produced) would be a most
desirable object in cases of aneurism ; for it is clearly by the formation
of concentric layers of fibrin nature endeavours to strengthen the walls
of the aneurismal tumour, and even occasionally effects a spontaneous
cure. And surely anything that would increase this tendency, ought to
be more calculated to assist nature in effecting a cure, than a cause of
ravating existing disease.
True Thoracic Aneurism ; Hypertrophy of Heart ; Disease of the Aortic
Valves; Albuminuria and Atrophy of both Kidneys; Cirrhosis of Lirtr, ijr., tjr.
Dr. Finn exhibited Pathological specimens of the above, and communi-
cated the history of the case.
Thomas Cahill, aged 53, a jingle-driver, unmarried, was admitted into
the North Infirmary on the 14th December, 1860, labouring under
bronchitis and anasarca ; the former having commenced about two
months previous, whilst the anasarca dated from a later period. Hi-
habits have been irregular and intemperate, and he has been under
treatment at various times within the last 14 years for syphilis, pain of
chest, acute rheumatism, bronchitis, &c. He has frequently fallen,
whilst intoxicated, from the seat of his car, and on one occasion expec-
torated blood immediately afterwards. Has suffered from hip-joint
disease from an early period of life, and, in consequence, one leg is much
shorter than the other.
General signs, — Face pale and oedematous; harassing cough, with copious
muco-purulent expectoration ; dyspnoea ; pains referred to various parts
of the body ; tongue coated ; appetite impaired ; pulse wiry and
accelerated, the artery, when pressed, communicating to the finger a
sensation similar to that produced by contact with a calcified substance ;
Medical and Surgical Society. 'I'M
the urine, on the application of the usual tests, yielded a copious precipi-
tate of albumen.
Physical 8igtM, — Visible pulsation of the arteries of the neck; slight
prominence of upper-third of sternum at right side; area of cardiac
dulness enlarged; dull resonance also perceptible in the course of the
ascending aorta and arch; bronchial rales audible throughout the chest;
bruit de soulllet heard over the region of heart; and in the course of the
ascending aorta and arch, over which Latter parts the character of the
murmur was much louder. Having remained in hospital for five weeks,
he was relieved to such an extent as to be able to resume, for some time,
his ordinary occupation. He was re-admittcd on the 1st March, 18G1,
in about the same condition as on the former occasion. The countenance,
however, presented in a more marked manner, the anemic character so
generally observed in connexion with albuminuria. There now existed
also marked turgescence of the veins of the neck. On the 19th March,
the anasarca had entirely disappeared, and the pulmonary symptoms
were also relieved, with the exception of occasional inconvenience from
the cough in the morning. He sometimes complained of dysphagia, but
did not always refer the difficulty, experienced in this respect, to the same
point. In the course of the month of May he suffered from a violent
attack of hematuria, which, for several days, resisted the usual treatment,
and reduced him to the last state of weakness.
During the months of May and June, the symptoms generally assumed
a more aggravated character; hemoptysis occasionally presented itself,
and he frequently complained of acute pain, referred to the region of the
heart. He died on the 11th July.
Autopsy. — Engorgement of the lungs, and effusion in the cavities of
the pleurae. Recent pericarditis ; adhesion of heart to the pericardium ;
the connecting medium being composed of soft plastic lymph, which
offered little resistance to the separation of the opposed surfaces. The
heart was large, globular in form, and firm in its texture ; it weighed 15
ounces. The left ventricle was hypertrophied in a high degree. The
aortic valves were opaque, corrugated, and thickened, and presented
vegetations at several points. The aorta itself was enlarged and saccu-
lated to near the termination of the arch ; it contained, throughout that
extent, a coagulum of moderate size, which was partially decolorized.
The interior of the vessel was thrown into folds, the middle coat havin^
lost its elasticity ; the internal lining membrane was pale, except at the
distal point of the sacculated portion, where there existed considerable
congestion ; at this point, also, the limit of disease was denned by a
narrow border of atheromatous deposit.
Cirrhosis of the liver, with diminution of its size, and the usual change
of form incident t<> this disease. The larger of the kidneys weighed
3 ounces and 1 drachm ; the other 13 drachms. Both kidneys were
na of th I -vy and I I >rk
pale, and almost v\ li. .1 L y free from any superficial irregularity; bu
ion oi either presented the characteristic pathological a]
osualh observed in connexion with albuminuria.
,— The hematuria, which lias been already noti ould
appear to have arrested th*- aneurism in its pn towards the naval
termination of this form of disease; and to the same cause, perhaps, if
not to the predominance of tin- white corpuscles in the blood, may be
referred the absence of congestion in the interior of the \ essel, a condition
which contrast! with that habitually observed under similar circum-
stances. It is difficult to determine the order of sequence which t lie
pathological phenomena observed, with the exception of the pericarditis,
which obviously completed tin' circle of organic change. The co-existence
of cardiac with renal disease, in a little more than half of one hundred
Boorded by Dr. Bright, would almost warrant a generalization on
this subject. This complication, however, ma) be regarded as the excep-
tional ease in this locality. Professors Harvey and O'Connor, of this city,
who have had opportunities on a large scale of obsen ingalbuminuria in hos-
pital ami private practice, state that they have rarely seen this disease
c implicated with heart affection. Professor Osborne, of Dublin, referring
to the co-existence of cardiac with renal disease, observes — '•This last
connexion has been placed in rather a prominent point of view by Dr.
Bright. In my cases the two diseases appeared to be combined, only by
both being the result of one cause." On the other hand Professor
O'Leary, of Queen's College, has seen, at Vienna, the two diseases just
referred to combined in the same degree of frequency as in Dr. Blight's
practice. Mere meteorological differences would fail to reconcile results
of experience so complicating as those adverted to.
A short Biographical Notice of Henri/ Pierrepoint, Marquis of Dorchester,
some time Fellow of the Royal College of Physicians, London. By T. W.
BELCHER, M.A, and M.B., Oxon, and Dublin ; L.K. &Q.C.P. Ireland, and
Physician Extraordinary to the Cork Fever Hospital.
Perhaps in no country does the professor of medicine receive so few
state honours as in ours : while lawn slee\es, in many instances, clothe
the industrious and zealous divine, and the judicial ermine enables the
once hard working lawyer "to live at home at ease" — like those comfortable
specimens of mortality "the gentlemen of England" — the earnest and
learned phvsieian can hope for no further success than to acquire an
enormous practice, which, even when made, is ever uncertain; and the
very pursuit of it so wears out mind and matter, that of most, it can be
justly said, "the weary wheels of life stand still at last." Hence the
profession of medicine is very rarely pursued either for love of it or for
gain, by the wealthy, and, in our day, never by the nobles. In a late
Medical and Surgical Society 2'.Yj
Dumber of Notes and Queries^ under the bead of "Noble Physicians,"
appeared a few lines relating to the oobleman above-mentioned. 'Jin's
Led me to inquire farther into the matter, and, by the kind assistance of
my learned friend, Mr. Richard Caulfleld — who consulted various works
for me in the Library of the British Biuaemn — I am able to lay before
you this short sketch.
Henry Pierrepoint, Earl of Kingston, was born in 1006, and was
educated at Emmanuel College, Cambridge, where, in due course, he
graduated. From early habit he was a studious man, reading for ten or
twelve hours daily for manv years; and although he appeared but little
in the character of an author, yet he seems to have had a great foundation
for being bo.
Collins, in his Peerage, speaks of him as a learned man ; and Walpole
in his work, Royal and Noble Authors, (by Park, iii. 229), quotes Collins
at some length to the same effect.
The following publications of his are still extant, viz. : 1. — " A Speech
spoken in the House of Lords, concerning the right of Bishops to sit in
Parliament, May 21, 1641." 2. — "Concerning the lawfulness and
conveniency of their, (the Bishops), intermeddling in temporal affairs,
May 24, 1641." 3, — "Speech to the Trained Bands of Nottinghamshire,
at Newark, July 13, 1641"; and 4. — "Letter to John Lord Roos, (hi?
son-in-law), February, 25, 1659."
He was called " the good Earl of Kingston," and was well read in
the fathers, schoolmen, casuists, civil and common law, medicine, and
anatomy.
For his proficiency in civil and common law he was admitted a Bencher
of Gray's Inn ; and, for his learning in medicine and anatomy, he wa3
elected a Fellow of the Royal College of Physicians of London.
To the latter^ociety he seems to have been more particularly attached ;
for he left to it his library of civil law books, the catalogue of which has
been published : — " Bibliothecoe Collegii Regalis Medicorum Londineiisis
Catalogus" writh an appendix, 8vo, 1757.
Antony Wood calls him " the pride and glory of the college," and Dr.
Munk in his learned book, " The Roll of the Royal College of Physicians of
London" (i. 262 — 274), lately published, gives an interresting notice of
this distinguished nobleman. Wood also notes an elegy, (now lost), on
him, by " John Crouch, sometime his domestic servant."
Throughout the great rebellion he was a steady adherent of King
Charles L, and attended him at his garrison at Oxford. For his services
the king created him Marquis of Dorchester in 1645. He survived the
usurpation, and died at his house in Charleshouse Yard, London,
December, 8, 1680, atat sua 74.
If we consider the immense benefits a man of this rank has it in his
power to confer on the poor and suffering on his estates, it is wonderful
£40 Hoi gh row ow I i«a.
>.\ noblemen practice medicine with an enlightened and liberal spirit.
- have learned mechanical trades, and statesmen have amused them-
pelves with children's g tinea ; but few have played the physician.
fusion of the Vagina, rendering Penetration impossible^ but not
Impregnation and ChUd-bearmg. By John II. Hougbtoh, M.lt.t ,8.
Eng., dbc., Surgeon to the Dudley Dispensary.
The perusal of Mr. Chance's interesting paper on "The Total Destruction
of the Penis not it Cause of Impotence,"* has induced me t<> send the
following record as a kind of corollary to Mr, C'a case: —
Whatever doubt may arise in the mind in reference to the voracity of
the statements made to Mr. Chance, and consequently of the truth of the
position he maintains, that destruction of the penis rendering penetration
impossible, is not a positive obstruction to impregnation, there can be
none in my case of the fact that occlusion of the vagina rendering pene-
tration beyond all question impossible, is not an absolute obstacle to
impregnation and child-bearing.
In reference to the point at issue, my case very much resembles the
two cases ([noted by Mr. Chance. It has, however, much interest in an
obstetric point of view, on which I offer no remark now. I publish it
simply in reference to the subject of Mr. C.'s paper, transcribing my
notes without further comment.
Mrs. A., aged 2o, one of the finest grown young women I ever >aw.
came under my care at the dispensary in the early part of 1858, on
account of a train of symptoms clearly indicating something wrong in the
genital organs. She had been under the care of several medical men
previously, but they had not directed attention to these organs. After a
little palliative treatment, 1 proposed an examination, which was readily
assented to. On separating the labia I was surprised to find the progress
of my finger arrested by a dense membrane, and on passing it backwards
towards the anus, 1 could not find any opening into the vagina, but on
passing it forwards towards the urethra, I discovered, close under the
arch of the pubes, a small orifice, with the most firm and rigid ed
posteriorly, and through this orifice I found it quite impossible to pass
the tip of my first finger, which is very small. In fact, the vagina (with
this exception) was completely closed by a dense cicatrix situated at its
orifice, so that the finger could not, at the most, be passed more than
an inch between the labia, so completely was the passage closed.
• Vol. xxxii., p. 39.
Mk. Houghton on the Occlusion of the Vagina. 241
On inquiry, I found thai Bhe had had one child before, and had been
attended by a midwife, who had allowed the head to remain uhalfbornn
for more than twelve hours. She slowly recovered, suffering great pain,
and having a profuse discharge from the ragina. She did not consult
any medical man, being satisfied with the assurance of the midwife that
all was right.
When Bhe got about, Bhe found that the functions of the parts could not
be performed as before. She went on for some time, hoping things would
gel right, l>ut at length consulted some medical men, who gave her no
idea of the oature of Inn- complaint, nor did they propose any examina-
tion.
1 gave her some medicines, calculated to improve her general health,
which was much impaired, and also to gain time to think over the case,
and to decide upon what was best to be done, when, one day, she came
to the Dispensary, and told me she thought she was pregnant — and this
Buspicion soon proved to be true. I now determined to wait till labour
came on — see what nature would do — and then deal with her condition
as circumstances arose. Labour commenced on the 29th of September,
1858, at 9 p.m., and I saw her on the following morning at 11. The
pains had then been sharp for some time — so sharp, in fact, that before I
could get there (two miles distant), a midwife and Mr. Meredith (who
lived near) had been summoned. On examining, I found the stricture
sufficiently dilated to allow me to pass my first finger, as far as the second
joint, with which I could feel the posterior fontenelle through the
os uteri, which was dilated to the size of a five shilling piece ; the mem-
branes were ruptured ; the pains were regular, and tolerably strong. I
left her for a time, Mr. Meredith kindly offering to see her frequently,
and send for me if anything happened. I saw her again at 10 p.m.
The pains had continued ; countenance good ; skin cool ; urine passed
freely; pulse 96, full and soft and regular; tongue clean and moist;
no thirst ; bowels opened ; head lower down, pressing on the cicatrix ;
the orifice admitted the finger freely. I remained with her an hour, and
during that time dilated the orifice so far, that I could readily pass three
fingers through it, though the margin was thick and very rigid then. I
again left her, Mr. M. promising to keep his eye on her and send for me
if necessary.
At 2 a.m., the pains had become so strong and the anxiety of the
patient and her friends so great, that Mr. M. sent for me. I was, how-
ever, engaged at another labour, and did not arrive till 5 a.m. There
was very little increase in the dilatation of the cicatrix, if any ; though
she had had hours of violent pain, with the head pressing firmly on it,
and pail of the scalp protruding through the orifice; countenance good;
skin cool; pulse 96, regular, soft; urine passed; tongue moist; not
much thirst ; bowels opened by oil which I ordered last night ; she
VOL. XXXIII., NO. 65, N. S. R
Db Houghton on the i
rt'ul, and bore her i Imirabrj , |
I. At 6* bad been made I
and ttrix remained as rigid ai ever, I made tv.
through it, one in the direction of each lacro-iliac synchondrosis. 'J
pains continued, but not bo strong or frequent; dilatation, however, went
on, and tin- head descended. At 9 a.m. I found the pr< till
obstructed by a very firm band of cicatrix on the right side, which had
a sufficiently divided. This 1 again Incised pretty freely where it
seemed to offer the greatest resistance. No bleeding of any oonsequen
followed the use of the knife, and the operation did imt cause any pain at
all. The dilatation now went on well, and the cicatrix did not offer any
further obstruction of importance to the descent of the head, At 1 1 a.m.
the head had made but small further progress, the pains Were becoming
1 i strong and less frequent, and the patient had become very anxi<
for delivery to be accomplished. Pulse 120; considerable feverishm
The head also seemed firmly fixed in the pelvis. Considering th
circumstances, and the history of her former labour, I now determined to
deliver by the forceps.
1 commenced the operation at 1 1T0 a.m., and applied the blades without
any difficulty. The head, which was found to be rather firmly fixed, was
soon released, after which 1 almost allowed nature to complete the delivery,
which took place at 11*45. Whilst I was attending t<> the child, which
was born asphyxiated, Mr. Meredith removed the placenta. The uterus
however, contracted badly, and violent flooding came on. Pressure BOOH
contracted the uterus, but it was not firm, and not near BO small as it
should be, and, as the flooding continued, 1 introduced my hand and
removed Some linn COagula and a small piece of the placenta which had
been left. The uterus was still disposed to relax, and the flooding to
recur, and, in fact, did return sharply. Grasping with the hand and the
cold douche to the vulva and the hypoga8trium, brought on linn contraction
of the uterus, which was maintained by pressure and the bandage, and
no further flooding took place. Two grains of opium were now given,
and in an hour 1 lift her composed, cheerful, and disposed to sleep, pulse
120. The child was resuscitated by halt' an hour's application of the
" ready method," after the warm bath, artiticial respiration, and cold
Sprinkling had failed to produce any decided effect. It is now alive.
Details of her progress are unnecessary, and would be tedious; suffice it
to say, that she made a good recovery, lint all my efforts to prevent a
further contraction were abortive to this extent, that when 1 last examined
her, I could only pass two fingers through the orilice. as far as the second
joints. She was perfectly restored to health. She miscarried since that
labour; and, on 22nd November, 1861, was again confined at the full
period. The orifice of the cicatrix admitted four lingers ; but required
slight incisions to be made into it to permit the head to pass.
CoLL&S on Reducible Inguinal HernuL 243
of Reducible Inguinal Hernia — Radical Cure performed according to
Wooefe taCBhod By W. Colles, i-'.U.c.s.l., one of the Surgeons to
Sseevens's Hospital.
Patrick M., aged 28, admitted into No. 1 ward the 27th November, 1800.
For aliout two years he has been labouring under an inguinal hernia of
the right Bide ; it has become very large, and he finds -rent difficulty in
retaining it in the abdomen; he has tried several kinds of trusses, but
in vain, and as be can not follow bis laborious occupation, ( farm labourer),
he Lb anxious to have something done for it; be would run any risk to
avoid being tin-own out of employment.
The hernia was Large, easily reduced, the ring and canal both much
dilated. Having just then studied the plan proposed by Dr. Wood in the
Medico Ckirurgioai Transactions for the relief of this infirmity, I resolved,
with the consent of my colleagues, to try it.
The man was placed under the influence of chloroform, I then made an
incision into the scrotum and loosened the integuments around, I passed
the index finger of the right hand into the ring, carrying on it the inverted
sac, till I felt the border of the transversalis muscle. With the left hand
I passed a very curved needle armed with a strong hempen cord to that
point, and while an assistant drew the integuments up I pushed the needle
through all the parts. Leaving the loop, I withdrew the needle on one
end of the ligature, which I passed through the outer wall of the canal,
and then passed the remaining one through Poupart's ligament. I could
not pass all through the same opening, as recommended. I was obliged
to have two openings in the integuments, about the eighth of an inch
apart. I then crossed the ligatures and tied them across apiece of wood.
For three days after the operation he suffered considerable feverish dis-
turbance, and pain in the region of the wound, but as the pain did
not extend entirely over the abdomen, and as his bowels continued
to act, I judged general peritonitis had not set in. I therefore allowed
the ligatures to remain fixed for eight days. On loosening them and
removing the piece of wood there came away a considerable discharge of
rather fetid pus. In two days more I removed the ligatures, and found
I had to use considerable force in removing the outer one. The abscess
continued discharging for a week, then gradually closed, and all bad
symptoms disappeared. When the swelling had subsided he was provided
with a truss and allowed to return home.
November, 1 861. — He has now applied at the hospital, one year after the
operation. He has been wearing the truss ever since, till about three
week- ago, when the spring broke. He now applies for a new one. He
says he never feels any inconvenience, or saw the slightest appearance
of the rupture, but he would not like to go without the truss.
The above case I consider as a case of cure ; although the man fears
R 2
'1 1 1 M lndl on Aphonia in TvbereuUmi ofthi Tjui
I • without the uu--, -till tlu- hernia has not made the slightest pi
since the operation, and for Borne weeks h>- might as well have had
no brass as the one he hai at present. How far th«: operation ma
justifiable requires farther experience.
On Aphonia in Tuberculosis of the Lumj. By PbOI B8BOB Mandl.
In opposition to the ruling and apparently well-founded opinion, that
the alteration of the voice occurring in the course of tuberculosis of
the lungs, is due to ;i local disturbance (catarrh, tuberculosis of the
larynx) Mandl puts forward another view. lit- -ay- these changes arc-
not always the cause ft" the anomalies in the formation of the \<
which may rather be looked upon as functional disturbances of the recurrent
nerve. Division of the recurrent nerve in animals gives ii-«' to aphonia,
difficulty of breathing, and closing of the glottis, so Mandl considers
that the aphonia in the course of tuberculosis is caused by the inlil-
trated upper portion of the lung and the bronchial glands pressing
upon the nerve. This aphonia accompanies tuberculosis of the left side
Seldomerthan of the right. The recurrent nerve of the left side, passing
between the trachea and OBSOphagUS, IS more protected from pressure than
on the right side. In children, before the fourth year, the alteration in the
voice is \civ rare, not frequent before puberty, and more rare in women
than in men. The first of these facts Mandl tries to unite with the
statement of Lanzet — that in young animals the section of the recurrent
nerve is not followed by aphonia ; the rare occurrence in females i-,
explained by the larynx being more like that of a child than that of a
grown man. After section of the recurrent nerve, or compression of it,
fatty degeneration and atrophy of the internal muscles of the larynx set
in, this Mandl ascertained on the dead body. By laryngoscopic inspec-
tion on the living, paleness of the mucous membrane, and limited mobility
of the right vocal chord were observed. {Jahrbuch, 1801, p. 90).
|n Blown Hunt!
1858, 1859, 18GO, 1861,
Ix Mkmouiam! But the last tribute of the noisy living, to the dead
great ones sonc from among as across the vast and unknown sea! But
a shorl requiem murmured o'er the grave ere the fierce din of life
deadens the mournful chauntl But a few flowers, sprinkled by the
hands of fellow-workers, ere comes the rush of men and of events to
trample them down into the yet fresh earth. In Memoriam ! Though
now a present and a national grief cries for a hearing, as Death is reaping
near the throne. In Memoriam of our best and greatest ; though the
tracings of memory be dimmed by the tears of a country's loss, and all
that is simple-minded and of generous heart subdues its private grief in
sympathy with royal woe !
Saddening and solemn though it be to hear read out the muster-roll
of Death, there is a pride in the names of these dead ones that robs our
grief of half its bitterness. Nor is this chequered sorrow the sole and
simple feeling that guides the recording pen in its attempt to trace the
lives of such worthies, and point the moral they bequeath. The epitaph
on the tombstone is not so much a tribute to the dead as a reproach to
the living. It is present penance for forgetfulness that must come — for
the oblivion, which as the golden sands -drop from the glass of time, will
most certainly submerge those who have established the strongest claims
on the world's regard.
Is it the fault or solace of our nature that memory clings at best but
feebly to the image of those with whom living we were most familiar,
whose company we loved, whose thoughts were springs of our own
actions, and whose language coined the issue of our minds ? Is this a
reproach to nature, and should we from it read the lesson that noble
deeds and lofty lives are profitless and vain ; or is such a reflection
pregnant with a nobler and a higher import — a steadfast hope in other
than man — the trust in a remembrance of good works recorded in a
higher sphere? Were it not for this secret and this constant faith,
whence could spring the ceaseless energy and steadfast purpose with
which the disciples of our art struggle with disease, often against
treachery from within and discouragement from without, knowing their
efforts must at best be tentative, will mostly be met by ingratitude, and,
frequently unseen, will of necessity be without reward. Who, disen-
/// .1/
jited by iuch ' bj euch know] I me alone mpplL
dispelling at last and for ever, the fairest and pun routh's bright
visions, would seek todev ote his life to medicine, it it were not for this
trust, and the splendid examples of the working in that trust that Death
now places before him ? For his science, could be foresee it, must, though
success wait on hi- steps, minister, most probably, more to tin- rices than
the misfortunes of men. Bis life, bo devoted, musl b constant triaL
Deficient in energy be must fall by the waj ; nor are there any of th<
convenient bavenson the road thai offer themselves to the weak of the list
callings. Without ability his labour is l>ut labour in rain, for no field bo
peremptorily requires at all times for its cultivation, a readiness of the facul-
-, a power of decision, and a courage for responsibility'. Sensitive by
nature, he must ever feel acutely not only the Bufferings h< - on far
his bread, but the Imperfections of the art he employs for their alleviation.
He, perhaps, may never Bee the beauties of a science so shifting and
inexact as Medicine. He must journey always in obscurity, mostly in
danger; and unless animated by the highest motives, can never cease to
pond. Deficient in means, he must fight without weapons: and not
only must bear his wounds with fortitude, but must hide them it' he hope
for mercy. Not only must he run the gauntlet of life, but for him th-
is no escape if he even utter a cry.
When will the hist of gold be staved? When will satiety of power
pall on men, that truth and purity may shed their radianee, and where they
fall, be blessed? When will the world's vision erase to view all things
through gold's alary glory, and Bee the beauteous sunshine on the work
with heaven's blessing? When will M Love thy neighbour" cease to be
a mouthing, and those who act upon the law, rank though with naked
feet, above the high in title ami in place? When will wisdom take pre-
cedence of rent rolls, and the pale beauty of christian practice beam upon
a calmer sea of hushed and human passions? — that what is good may- no
longer be great by ehanee. hut by desert ; and what is virtuous in aetion
astonish the world no longer when wedded with success ?
But let us beware, lest the recollection of not one only whom death
here links with his rarer brethren, but of others whom contrast with
the examples before as conjures up, lead us to lay too much upon
the world and too little on ourselves. Grievances are mostly the com-
forts of the weak ; and in pointing to the exceptional successes of men
even of the highest merit, we should not charge the world with an
obliviousness of benefits it never knew it had received, and a disregard
of merit it was unable to appreciate. For the world is a noisy world,
and withal exceedingly busy. It has scarcely time to seek out merit
obscured by its own modesty. It is unable to decide on matters of
abstract acquirements, and on a skill remote from its own experience.
And not unseldom, must we confess, that when the world calls upon
Iii afemoi iam -j \ 7
in for a choice, we are found to be doubtful of our own champions',
and frequently engaged in reviling onr Idols. Success in so rare, in the
ial point of view, that those \\li<> can assist one fortunate to attain it,
would be more than human iftheylenl tiheiraid; and dissatisfied with
Ourselves for characteristics thai the world loves not, wti may possibly
blame for its coolness, the regard we ourselves have deprived of Its warmth.
The very character of the medical niiml sufficiently accounts for the
rareness with which Medicine, Is hidden to a share In Che honours the
world can bestow. Congenial in private life; leader in social progress;
foremost In acts of charity and of mercy; the practitioner in medicine
thrown into public life is at once unsuited and out of place. With
a youth given to studies of an inexact character, his views present none
of that distinctness that satisfy the reason ; nor are they enunciated with
that vigour and charm that only those trained in exact science can
acquire. The highest functions of the mind are given to analysis. The
greatest cultivation is bestowed on the senses. Consequently, though he
can please, he can seldom control or create ; and though he may be
esteemed for his varied knowledge, he is seldom sought for the solidity
of his powers. Perhaps no medical man was ever feared ; perhaps but
few who are not widely respected. But to achieve the success we allude
to, there is nothing more fatal than reputable benevolence. For the
world gives nothing to goodness in the abstract ; and perhaps it is more
to be pitied than blamed, that its rewards are sought from it by daring
rather than desert, and obtained through its fears rather than its gratitude.
If this then be no prejudiced glance at the various causes which
operate to the exclusion of so many from success and honours, that
similar application and integrity would insure in other walks of life, it
may fairly be assumed that success in medicine, in the full and worldly
acceptation of the term, necessitates the highest endowments and capacity,
and when obtained, is in itself proof of their possession. Nor weighing
that success with the merits of the man, can any stronger evidence be
found in the history of the profession at all times, than presents itself
spontaneously in the person of Sir Philip Crampton.
Foremost among men of whom Irish surgery is proud — singularly
gifted by nature, and favoured by good fortune — Sir Philip Crampton
stands out forcibly as the brightest ornament of the profession he adorned.
The family from which Sir Philip descended, originally migrated from
South Cottingham, Notts, and settled in Ireland in the reign of Charles
II. Sir Philip was born in Dublin ; was apprenticed to Solomon Richards ;
and saw active service, as staff assistant-surgeon, at the invasion of the
French in 1798. Appointed surgeon to the Meath Hospital before he
had completed his twentv-iirst year, and even before obtaining his
diploma, Philip Crampton began practice in Dame-street. Finding and
no doubt, not to his surprise — that practice at so early an a^e did not
//: 1/ - m.
Sow in irilh great rapidity, Crampton, in con junction with P li rkan,
irho took the anatomical department, established the first j<ii . oo]
matomy and aurger) in Dublin. He himself lectured on physiolo
pathology, and surgery; and the increase in his practice, which I
tine encoui happened at this time to be materiall) assisted by
the accident that befel the waiter at the Richmond Tavern, op
Philip's house in Dawson-street. The emergency was Likely to ba\ «■ pro
fatal; and Orampton g*>t much commendation for the readiness with « hich
he proved himself equal to the occasion by performing tracheotomy.
At the time of the death of Mr. Stewart, Philip Crampton had bei
chief Burgeon to the Lock Hospital. He resigned this on receiving from
the Duke of Richmond the appointment of Surgeon-General to the For
in Ireland, lie became Surgeon-in-Ordinary to the Bong ; and was m
a baronet by her present Majesty in loo'.).
M ire perhaps than most men, ami certainly at any one period of his life,
more than most men of his age, Sir Philip Crampton enjoyed life. Nor
is it saving too much to affirm, that at the age at which the appetites and
faculties usually decay with failing nature, Sir Philip's animal spirits
were at their highest, and his pleasure in living most intense. With him,
Life itself was an enjoyment which acquired but little additional /.est from
the appliances of modern luxury. He was passionately fond of athletic
and out-door exercise. He was a first-rate rider, kept his own pack of
hounds, and seldom missed a day'- sport when in the height of his prac-
tice. His senses consequently partook of such acuteness, and his percep-
tive powers were BO vivid, that these in themselves enabled him as it
were to dispense with intricate processes of thought, in forming a swift
and correct conclusion in any case that came before him. llis diagnostic
powers were unrivalled. Disease was to him QOt BO much a puzzle as a
picture, for the very difficulties of a case were to him but so many fea-
tures. With him surgery was not so much a profession as an instinct,
lie operated consequently as a master. His boldness never partook
of rashness ; for his experience had been unequalled, and his know-
ledge of anatomy was profound. He could consequently arrive at
results in a Less time than most men take to lay down their premises.
But let no one entertain the vain thought that the | D >'t even such
gifts as those with which Sir Philip was endowed, can achieve a like
reputation, and a success as glorious, unaccompanied by the keystones to
this admirable character — industry ami perseverance. For forty years
Sir Philip worked unremittingly in the wards of the Meath Hospital ;
nor did the unceasing claims upon his energy, of both his public and his
private practice, prevent him from carrying on with ardour those literary
and zoological pursuits in which he excelled. His essays and papers are
to be found in profusion, in all the medical periodicals of the day. His
discovery of the Musculus Cramptomanus by wThich the eyes of birds are
In Memoriam, 249
accommodated t<> the different distftncei of objects, obtained hie election
into the Royal Society; and his abstrad scientific acquirements irere
iucb as ensured his repeated re-election to the President's chair, both at
the Zoological Society and the College of Surgeons.
In every sense of the word Sir Philip CramptOD was a gentleman; and
on his claims to that title alone, would have achieved ;i name, without the
•id of his profession. His tastes were elegant: his manner, in the
highest degree courtly and fascinating. Of commanding tonn, and rare
beauty; of noble nature, and fearless disposition; he displayed at once a
merit too signal for detraction, and compelled an admiration too deserved
for envy. For eloquence he had no rival in the profession. His orna-
ments were chaste and felicitous. His method of arrangement such as
presented the most complicated subjects, at once in a lucid and attractive
form. But what, perhaps, tended mainly to place him in his elevated
position, and to maintain him where others, from the inconstancy of the
great or failings of their own, must have descended, were his social qualities
and conversational powers. His language was copious, and well chosen ;
his style pleasing, though emphatic ; his fund of anecdote and raillery in-
exhaustible, and inoffensive. His own feelings were too sensitive to admit
his giving pain to others ; nor could the least of his admirers allege, that
his humour, which was great, and his sarcasm, which was powerful, had
ever been employed to ridicule the weak, or to deride sacred things.
The bust of him by Moore, in the theatre of the Meath ; the crowds
that followed him to the grave ; the reverence with which his name is
still mentioned ; evidence the deep affection Sir Philip had inspired
among all classes.
The " Dublin Dissector" has perhaps done more to further a knowledge
of practical anatomy than any other work that ever issued from the press.
On the ground of its authorship, therefore, Robert Harrison is deserving
the sincere and lasting respect of his professional brethren ; a tribute they
will, moreover, pay willingly and with regret to the author of the
Surgical Anatomy of the Arteries, and his classical contributions to the
Encyclopedia of Anatomy and Physiology. Surgeon to Steevens's Hospital,
Professor of Anatomy in Trinity College, to which he had been translated
from the College of Surgeons, an excellent lecturer, an honourable man,
and a staunch friend, Harrison was snatched away, prepared by his
blameless life, indeed, but not by the warning he received. He was heard
at the hospital in the morning to express a wish he might die suddenly,
and not by such a lingering death as Sir Philip's. During the night he
was seized with apoplexy, and next morning was no more.
Unappeased by the victims from our ranks in the year 1858, nor
content to wait for the hecatomb of 1860, Death took from among us, in
In M m
Deeembef k> whom obstetric medicine u no little mdeb
tie present dignified position in Europe. William Fethebston II
Mont died <»u the % 1st d December, at bis I d •n-
tare. His reputation bad extended and raised tbe credit ot Irish
midwifery wherever scientific medicine bad cultivators throughout the
world. Not w as that celebrity at all incommensurate with hi- local fame,
the extent ol bis abilities, and the blameless character of his life. With
indomitable energy, with profound transcendental knowledge, and \
ring a rare acquaintance with the science of embryology a- cultivated
by the German school. Dr. Montgomery at once was the most lucid
expounder, the most skilful practitioner, and tin- most advanced cultivator
of his art. To his unaided abilities he owed bis success; to bis ena
to his devotion to Bcience, and to his disinterestedness, his survivors
indebted for the Obstetric Museum, which own- no superior in Europe,
Extensive as it is, the collection formerly in the College of Physicians,
and now enriching Queen's College, Galway, was the work of his own
hands; nor could the unceasing duties of most extensive practice, or the
advance of years, prevent him from adding to the collection up to the
latest period of his life. His career was precisely that which might have
been predicated from his youth, lie entered Trinity College, Dublin, in
the year 1817, and there received a scholarship, bestowed only upon th
who, like himself, displayed rare classical tastes and acquirements. To
these, abiding with him through life, may be referred that pleasing style
of delivery which made his lectures so popular, ami the lucidity and gn
which gave them so rare a value; and the same elegance of idea and
happiness of expression, may be abundantly observed in his classical
work On the Siijns and Symptoms of Pregnancy, which, though it was
not needed to extend his reputation, has certainly served to place it
beyond dispute. Of equally signal merit, and, perhaps, of greater*
originality, are his observations on the Spontaneous Amputation of the
Fetal Limbs in Utero, which alone would entitle him to the first position
in the walks of science, even without the additional fame that justly
attaches to the author of " Personal Identity, " and " Succession of
Inheritance Legitimacy " in the Cyclopedia of Practical Medicine ; con-
tributions which, from the learning and power of grasping and har-
monizing facts that they abundantly prove their author to possess, are
worthy to be placed among the most valuable monograms in this or any
language. Enjoying a most extensive and lucrative private practice, Dr.
Montgomery attained the highest dignities his profession could bestow.
He was a Fellow of the College of Physicians as far back as the year
1820, but he did not proceed to the degree of M.D. until 1852. He was
also elected President of the College, and held the Professorship of
Midwifery for thirty years, worthily fulfilling the duties of the post,
whose institution was due to his early exertions.
In Metnoriam, 251
Snatched away, Like Harrison and Montgomery, while busy at Mi post,
Henri .M\k>ii now claims our furrowing mention. To many there
are given intellectual and mora] powers which permit their possessor*,
if (he eoast he hut elear, to steer through life without shipwreck;
ami which, if lmt enabling them to surmount unwonted dangers, at least
])re\eut them courting imiiir. --ary disaster, lint few men po->e-s that
strength of will and that (dearness of moral vision whieh in emergency
endow them with forethought, and, nerving the hand to seize the helm
with unflinching grasp, render their trials and their perils subservient to
progress; Hut of such a rare combination was the man who filled for so
many years, so prominent a position among the physieians of his time.
At 12 years of age he was destined by his father, the rector of Killinane,
to agricultural life; and, until 15 years old, his studies were entirely di-
rected to corresponding pursuits. In 180G, however, being then 16 years of
age, his ambition was excited by a chance companionship with a stranger,
a Fellow of Trinity College. He abandoned his rural occupation ; and
at 17, entered the University of Dublin — firstly under the tutorship
of the present Right Hon. P. C. Crampton, and subsecpaen tly under
that of the Rev. Dr. Sandes, afterwards Bishop of Cashel. His views
were for the Church ; but having about this time become strongly
impressed with the religious tenets of the celebrated John Walker, he
determined to enter upon the study of surgery instead. His design wras
to serve in the Peninsula ; and acting upon the advice of his cousin, Dr.
John Crampton, he became one of the pupils of Sir Philip. He happened,
however, to wound the index finger of his right hand, and the subsequent
loss of a portion of it, compelled him to modify his plans of practice.
In 1818 he graduated in medicine, and took the licentiateship of the
King and Queen's College of Physicians. In 1820 he was appointed to
the vacancy in Steevens's Hospital, created by the promotion of Dr. John
Crampton. He wras one of the original promoters of the then medical school
in Park-street; and, in 1827, succeeded Dr. Whitley Stokes in the
lectureship on the practice of medicine to the College of Surgeons. This
appointment, from the extent of his private practice, he was compelled to
relinquish in 1832. Made Physician-in-Ordinary to the Queen in 1837,
he received a baronetcy in 1839. He became President of the College
of Physicians in 1840, and Senior Physician to Steevens's Hospital in the
same year, on the death of Dr. John Crampton, his old relative and friend.
So singularly unchequered a career of prosperity, succeeding to a youth
whose education and whose plans had been as signally shifting, points at
once to the adaptive genius of the man and the inherent vigour of his
nature. Matured by the experience he soon acquired in the discharge of
duties under which a less determined mind must have succumbed, Sir
Henry Biarsh made those valuable endowments subservient to inductive
medicine with a facility and success to which the only parallel can be
In Memoriarn
found m tin* practice oi Robert Bentley Todd. In th<- ptu
d knowledge; in the tracing the causation of morbid pr<
to an ultimate fact; in the endeavour to reconcile the clinical featun
disea Sir Henry Marsh was alike- sealoui and successful. I
confidence he felt in himaelf he inspired in others; hii msequently
was as steady es it was rapid, and when secured was ai firmly maintained.
Hi- moral was his incentive to sction. His trust and his faith the
measure of Ins buc< ess. Belies ing in the dependency of result upon can
he aimed not so much to succeed as to deserve. Not limiting his b
the restricted area of the senses, with no nan-owed view of labour and
of thought, he was impressed earnestly and Btedfastly with the beneficence
of design, and the justice and right of things as they are. Having no
pticism he had no mistrust, but used gratefully, and with confidence,
the means nature placed at bis disposal. His work was consequently
worthy even of the highest intellect, and was stamped with a beauty that
graces but seldom the fruits of even greater learning and genius.
Knowing he did his best, anil knowing by the light that was in him th.it
that best was good, he was at once prompt in his theory and self-reliant
in his practice. For to him labour was support independent ^'i oral
nor could applause add any thing to the silent pleasure in doing good
and in mitigating suffering, he felt as a Christian Philosopher.
Sir Henry Marsh was of good family — no small advantage to a man
whose professional success, as in medicine, depends so intimately on his
social qualifications. His ancestors originally resided in Gloucestershire,
one of whom, Francis Marsh, afterwards Archbishop of Dublin, a settled
in Ireland, and died in 1693. Sir Thomas Molyneux, the first medical
baronet ever created in Ireland, was one of his maternal ancestors. The
prestige of his name Sir Henry did not suffer to deteriorate by any lack
of courtesy and hospitality; but by the free display of these virtues in
his own person, and on all occasions, he mainly contributed to invest
the Dublin School of Medicine with a social reputation in no unworthy
harmony with its deserved scientific fame.
Sir Henry Marsh freely indulged those literary tastes which to him
were so congenial. He was a prolific author, ami the extent and variety
of his communications to this Journal, are themselves abundant testi-
mony to his exceptional powers and attainments.
On the 1st December, 1SG0, Sir Henry Marsh was on the point of
leaving his house a little after nine in the morning, when he was seized
with vertigo, and, falling, fractured a fibula. On the same day, at seven-
teen minutes to one, he expired. His remains repose in Mount Jerome
Cemetery, having been followed to the grave by a larger concourse of
mourners than had been present at any interment in Dublin for many
previous years.
* Founder of Marsh's Library.
In Memoriam. 253
No school in Europe, of s surety, ever sustained such grievous Losses in
so short a time, or furnished death with such illustrious victims, as the
Dublin School of Medicine during the last twelve months. Long indeed
will Bteevens's and the sfeath remember the fatal cycle which robbed them,
not only of their Leaders, bu1 of those who stood oexl to replace them.
Scarce had the sorrow for Sir Henry Marsh begun to lose some of its
poignancy, than death, restless and insatiate, seized upon thai brilliant and
eloquent man. whoso talents and whose energies bad made the name of
Porter respected, wherever scientific surgery owned a footing.
Classical as a writer; brilliant as a lecturer ; earnest as a worker ; and
excellent as a man, William Henry Porter was one of the brightest
ornaments of which the Irish Medical Profession can boast. His classical
acquirements — stamping every page of his work on Aneurism, of his book
on the Larynx and Trachea, of his Essays on Syphilis, and of his Lectures
on InHammation and Lithotomy — had mainly contributed to his brilliant
academical successes when a student in Trinity College ; and the fruits
of the cultivated training he had received in early life, displayed
themselves at maturity, undiminished by any loss of that remarkable
energy which had early been one of his chief characteristics. Having
entered upon the active duties of professional life, this vigour of purpose
was in itself sufficient to achieve for him the reputation, which as long
back as forty years, attached itself to the operator who had successfully
applied the ligature to nearly all the larger arterial trunks. Of so vigorous
a turn of mind, it is not astonishing that William Porter should soon have
made himself conspicuous for the daring of his operations, attended, as
they were, by singularly happy results. The particulars of his attempts
on the innominata artery and its fortuitous issue, are long since familiar
to the student of a special department of surgery. The patient had an
aneurism of the innominata. The operation was complicated by circum-
stances of peculiar difficulty. When the artery was exposed it was found
to be atheromatous. The ligature was, consequently, not applied, but the
irritation set up eventually led to consolidation of the aneurism. Since
then analagous steps have, in other hands, led to cure of aneurism in the
subclavian. One of the last operations of Mr. Porter was the ligature of
the femoral artery, at the upper part of the triangle ; and the particular
advantages of the incision being made parallel to Poupart's ligament, as
Was done on that occasion, are described in our sixtieth number, by his,
son, Mr. George Hornidge Porter.
An earnest man, William Porter had strong opinions. But as he
Was a thinker, these opinions were sound; though, as he was strikingly
original, they were not always readily received. But as he had worked
for them and always conscientiously, he was not the man to give them up.
He defended them always with keenne-s and clearness ; but though,
from his thorough spirit of independence, he would not hesitate to crush
In M m
■ urtnidable antagonist, yet, never did be disdain to remov< the
simplest difficulties that beset the moat youthful oi li i ~> students.
of the manner, and not a little of th<
Sir Philip Crampton, descended to his favourite pupil, 1 •: B
•• 1 » yak," as Sir Philip and his intimates need fondly te call him,
hold, like his master, a surgeoncy at the Heath Hospital, an<l, in
compliance with the last request of Sir Philip, encased, with his own
hand-, his body in tit. Francis Rynd enjoyed a large public and
private practice, and a social position altogether unequalled. The fii
in the wards of the Meath Hospital, extended 0V6T twcuiy-M\
and, though scarcely securing for him a scientific position commensoj
with his social status, procured him a tame of a high character, and most
uvdlv deserved. Shrewdness, and a turn of mind eminently practical,
ate but seldom associated with habits and methods of thought, admitting
at literary distinction ; nor do we find that any exception to this can be
found, either in the work of Francis Rynd <>n Stricture of the Urethra,
or in his contributions to this or other journals, some of which, notwith-
standing, were in progress at his death. Bui his operative -kill was
perhaps of so high an order, that it would fairly have graced a rarer
scientific zeal, and information more extended and profound. Francis
Rynd was tall and of aristocratic appearance; his head was remarkably
intellectual, and his brow noble. His manner was dignified and attracti\ c,
and by the sick bed, most affectionate and tender. His patients were,
without exception, his friends ; for his tact and delicacy, in truth, were
admirable ; and, considering how rare and how indispensable are these
requisites to social success, it is not surprising that, conscious of their
possession, he should have aimed at a celebrity more local than extruded,
ami a reward more practical than conspicuous. Francis Rynd knew his
profession well, but he knew men better. Yet he was no seltish man.
He was offered, both by Ford Fglinton and the present Yice-Kov, many
opportunities for profit and advancement, which would have tried, very
severely, one Lass disinterested. Bui he resolutely declined to prolit by a
ard won through professional intimacy, and set a noble example to
not a few of those w ho admired him the least. For work that was not
to be done Rynd may have been unsuited ; but no man could do better,
if so well, the work which he had to do. He estimated rightly the value
of ties between person and person, though he might often be charged
with meting these at the cost of professional intimacy. Yet we should
hesitat he was unwise to value the worldly wisdom so peculiarly
his gift, or to strive but little for an admiration labour only could elicit,
at the cost of an affection his character so signally compelled.
Fortunate like Sir Philip in his life, more fortunate than he in the
manner of his death, Francis Rynd, respected by his colleagues, and
/// Memoriam. 2f">5
beloved by bis friends, received in the grave the best tribute to bis merits
— the unrestrained tears of the nobles! who followed aim. To these bis
admirers ma y al least point in evidence of the power he possessed to
lire 1 1 ii- confidence of his patients, and of the loyalty with -which that
confidence was invariably preserved.
Among those grouped around the death-bed of Sir Henry Marsh,
prompt al the call of suffering, and eager to solace the last moments of
their professional brother, stood the Nestor of Irish surgery, destined
Boon — and how speedily? — to follow him on his long journey, and in
like manner, to be mourned by the many who had benefited by his skill,
and profited by his example, That skill was profound. That example
was indeed brilliant. But it cannot be said that the ability of James
WlLlAAlA CusaCK was enhanced by the charm of eloquence, or that the
wisdom of his precepts was rendered more impressive by the attraction
of his manner.
Descended from an ancient family, James William Cusack was
admitted at the College of Surgeons in the year 1812. He had pre-
viously obtained a Scholarship in Trinity College, and, on taking his
degree, a classical gold medal. He was early appointed Resident
Surgeon to Steevens's Hospital, and subsequently, to the Surgeoncy of
Swift's. In 1850 he took the degree of M.D. in the University of
Dublin, and in 1852 was elected to the University Professorship of
Surgery, founded in that year. He was three times President of the
College of Surgeons, and, on the death of Sir Philip Crampton, was
made one of the Surgeons in Ordinary to the Queen.
He was great without seeming to be great, and, we believe, without
knowing he was great, for to the last he could never overcome a nerv-
ousness which amounted almost to infirmity, and which his assumed
brusqueness of manner could but imperfectly veil. " It was not," said
he, speaking to the Editor of this Journal, in allusion to his abandonment
of operations, " that my hand is not steady," and he held it out, bein«-
then more than three score and ten years old, as firm and as steady as it
had ever been, "but I am so anxious, before operating, that I feel the
strain too much for my system. You will be surprized," said he,
" when I tell you that from my first to my last operation, I have never
been able to sleep the night before, but lay thinking how I should
operate, what difficulties would arise, and how I should meet them."
Lecturing, this nervousness was obvious enough, but few would have
observed it when he handled the knife. Then, he seemed possessed of
the calmness of a master. Prepared for every emergency, his internal
resources under perfect control, he left the observer in admiration, not
more at the .-kill of the performance than at the power of adaptation he
displayed. One living surgeon — and perhaps only one — to whom the
//' M. moriam
•
spurting from the posterior tibial fa imputation
with the same iweep of tin- knife, can, in thi~ rare faculty, compare with
James W Uliam Cu And inasmuch as this faculty essentially cons]
in the power t»> compel the mind to ignore its previous workings, and
e the hand I ih plan, so it is ited with the art of foi
spontaneously what may have been unfortuitous, and which, it shown to
be remembered by the operator, will never be forgotten bj bis audien
Though cautious, ret bold; though desirous of aiming more at exceUei
. and completeness than at daring, rapidity, and effect, he
tempted to a display which might have affected him injuriously, had he
uot possessed this admirable instinct of readiness and self-command. M I
was operating oner," he said to us, "on B ruse of stone. They wen- all
there, Crampton, Peile, and so on, and they must needs time me. I cut
into the rectum there and then. But they didn't Bee it and I didn't tell tl.
But notwithstanding all the patting on the back I got, and what a line
fellow they said I was, you will never see me operate when I'm timed
again." And though the man recovered, Dr. Cusack never got over his
dislike of being timed, nor would he allow himself to be minuted if he
had a suspicion it was being done.
Thousrh his tame was so universal, his ability as a writer was not com-
mensurate with his skill as a surgeon. Of his deficiencies in this respect.
as in speaking, he was himself well aware, and often indeed did he exp:
his regret, in conversation with his intimates, at having omitted to remedy
his want of readiness and fluency. It is remarkable, however, that he
was himself accustomed to attribute a great part of his subsequent fame
to his paper on the Extirpation of the Lower Jaw; but, as is not
uncommon with men of great abilities, he may have assigned undue
importance to those powers in which his excellence was least marked.
Thousrh a great and most successful operator, Dr. Cusack was one of
the Btaunchest advocates of conservative Burgery, and regarded operations
as the opprobia rather than the glories of his art. Vet he owed no small
measure of his success to his operation on the carotid. 'Hie patient was
a man oi note, who had been wounded by a bullet in the neck, at Tip-
perary. He was dying from hemorrhage, when Cusack saw him, and at
once cut down on the artery and tied it. The patient recovered ; and,
as in the similar emergency oi Sir Philip Crampton, the practice of the
operator rapidly increased from that time.
As a lithotomist James Cusack was eminently fortunate. He operated
for stone G5 times, and his mortality was remarkably low. He preferred
lithotomy to lithotritv ; and his preference, no doubt, took its origin from
a case in private practice, which, subsequent to the use of the lithotrite,
terminated fatally from diffuse inflammation. Sir Philip Crampton
assisted in the operation, and testified to its skilful performance.
Although, however, we do not find the highest literary capacity in the
/// Miemoriam. 257
writings of this eminent man — yet those writings, when collated) assume
no inconsiderable form. Bis papers in the Dublin Hospital Reports
extend from 1*17 to L830, and evidence the eminently practical tone of
his mind From 1882 to 1846 Dr. Cusack contributed many papers to
the Dublin Journal of Medical and Chemical Scienet ; and ap to the period
of his death bis contributions i<» these pages were not without materia]
influence upon tin* progress of philosophic and operative surgery. We
would especially direct attention to Ids papers on the Treatment of Aneur-
ism by Compression ; on Venereal Disease of the Testicle; on Rupture
of the Bladder; on Cleft Palate. They are abundant evidence of the
originality of his mind, his sterling and unaffected sense, Ids boldness,
and his dexterity. Throughout the present and the first series of this
Journal arc to be found many cases deriving their great value from the
appended clinical remarks of Dr. Cusack. His two papers, moreover,
written jointly, and published in our fourth and fifth volumes, on the
Mortality of Irish Medical Practitioners, have laden the profession with
a debt of gratitude as lasting, as that which Science already owed to him
and William Stokes.
In James Cusack, as it has elsewhere been well and affectionately
expressed, the public had to mourn a physician, as well as the most bold
and dexterous operator of his day, and the medical profession in all its
branches sustained an irreparable loss in the passing away of the man
who shed a lustre on the Dublin School of Medicine, who was the em-
bodiment and impersonation of professional honour and honesty, and of
whom, dying full of years and honours, it may be said, as Pope did of
Addison, that throughout that long and unsullied career
" He sought no private end,
He gained no title, but he lost no friend."
He was a great medical surgeon, observant, cautious, and far-seeing ;
and his practice (as well as the actions of his life) was characterized by
strong common sense. No one ever heard him utter a frivolous or foolish
expression, and he was utterly devoid of personal vanity. In the good
old days of apprenticeships, he educated more surgeons than any other
man in the profession. Undemonstrative, yet firm in opinion, his patients
accepted his word as law, and lie was one of the safest consultants to whom
a professional brother could possibly have recourse.
He died at his post. His unobtrusive, honest life stayed, as it should
have done, in action. He had suffered long from diffused bronchitis —
the symptoms of which became aggravated, and speedily displayed a fatal
character, after his visit to Steevens's Hospital, on the 14th of September.
On the 25th the profession lost in Janu- Cusack its chief, and every
Irish surgeon a brother. Rich in worldly wealth, the tribute of the public
to his long service, he died possessed of yet greater treasure than the world
VOL. XXXIII., NO. G5, N. s s
In Memorial
■jive — the store secured by a heart of gold thctt ncu-r beat but nobly
through a irell-spent lii
Still to the faltering pen come for our tender record the nan.
Ledwioh, li.vuKAN, KnrosLEr, Bbxbxton, Tah est, Cath< utj Lb
O'lii.iKNK; nor either they, or those of brighter note, placed ai the herald
Ol tame would BOUnd them, but as death Called them away. And now
that the proud wave of their lives has dashed into the BOOn-forgOtteD
>pray against the rock of the (J rand and Immutable Will, and all the
treasures that they bore lie on the itrand, the common property of men,
let us take to ourselves the light of their just lives, ami, with ai high a
courage as they owned, and with no greater care tor self, foster the
\n\- that they loved, and that now so bitterly mourns them. For that
nee, though owing them much, is but imperfect yet. But the better
part of man, which is of perfect love, owes them still more. Owes them
the debt of their self-sacrifice ; of their deep sympathy ; of their im-
rlinehing toilsome lives which lifts its voice higher than monuments,
and tells of their works more than all the conceits of art, and all
the tortured flattery of design; ringing in every tread of their old worn
wards, and in the sob of every sufferer lying where they have ministered,
into the Song of Hope that such as they, the pure in heart, .shall see tin-
face of God.
Medical Superintendence of Aeylume. 259
MEDICAL SUPERINTENDENCE OF ASYLUMS.
[In the Review on Insanity in the lasl number of this Journal,
Vol. xwii., p. 369, there appeared an account of a Deputation
to the Chief Secretary (Sir Robert Peel) iVom tin- Association of
Medical Officers of Asylums, in reference to the Medical Superin-
tendence of Hospitals for the Insane, and advocating the views of
the Resident Physicians. We have sinee been requested by the
Visiting Physicians to insert an account of a Deputation from their
body, which waited on Sir Itobert Peel, in reference to the same
question — a request with which we feel bound to comply, on the
principle of audi alteram partem. — Ed.]
A Deputation of the Visiting Physicians of Lunatic Asylums in
Ireland, consisting of Drs. Cusack, Croker, Banks, Law, Tuohill,
Ferguson, dimming, Dillon, and O'Meara, waited on the Chief
Secretary (Sir Robert Peel) on 31st August, 1861.
The object of the Deputation was to lay before the Chief Secretary
their views relative to the respective duties of the Visiting Physicians
and the Resident Medical Superintendents of Asylums and Hospitals for
the Insane. The fact of the Medical Superintendents having brought
under the notice of Sir Robert Peel their opinions, rendered it necessary
for the Physicians to come forward ; the more especially as a statement
had been made by the gentleman who addressed the Chief Secretary,
which might mislead, and which the Deputation wished to correct. It
being known that the rules for regulating Lunatic Asylums were being
revised, rendered the present occasion peculiarly opportune for directing
the attention of the Government to the results of the experience of the
Visiting Physicians on this most important subject.
The high state of efficiency of the Irish Asylums, to which Sir Robert
Peel bore testimony in the House of Commons, the Deputation thought
might fairly be attributed to their having Visiting Physicians. The
Deputation further remarked, that any modification of the rules regu-
lating the relative duties of the Medical Officers which would have the
effect of placing the insane more under the medical care of the Superin-
tendents than they are at present, and thus so far withdrawing them from
the care of the Physicians, would act most injuriously in two ways !
first, in limiting the advantage they at present enjoy of the skill and
» cperience of men constantly engaged in general practice ; and, secondly,
in the lots to the public of the knowledge and experience acquired by the
Visiting PhyBician in his attendance on the inmates of Hospitals for the
[nsane.
> 2
iieal Superintendene ylum».
Dr. Lalor, the Medical Superintendent of the Richmond Asylum, wl
exp: his views on the subject ol the relative duties oi the Medical
Officers of Asylums, referred t<» the Report of the K' l Commission,
and its recommendation, ami, in so doing, made a statement us to the
constitution of the Commission, which it was the duty of tin- Deputation to
correct, He -aid — •• When 1 consider that this fa tin- recommendation
of the medical members of the Commission, who have bad larg oal
practical experience of tin- subject, and who have obtained a high repu-
tation ami promotion in consequence, L cannot think that you will allow
it to be outweighed in vonr mind by the Bingle opinion of a gentleman,
who, however high his character may he in some Other branches of tin-
profession, has had bo few opportunities of acquiring knowledge in thi
It is necessary to refer to the constitution of the Parliamentary Comn
sion, for the purpose of correcting this error, which ha- been before
alluded to. The Commission consisted of Sir Thomas Redington, Mr.
Andrews, Q.C., Mr. Ledwidge (a Lawyer by profession), Dr. Corrigan,
and Mr. Wilkes (now a Commissioner in Lunacy, but formerly a Super-
intendent of a Lunatic Asylum).
There were, then, only tiro medical members — Dr. Corrigan, Physician
to the Queen, and Mr. Wilkes, who is a surgeon and apothecary. It i-
scarcely necessary to observe that Dr. Corrigan holds a position of the
highest eminence in his profession, and enjoys a most extensive practice.
For seventeen years, he has, moreover, been Physician to the Hospital-
of the House of Industry, and the Lunatic Asylum which was connected
with them, containing upwards of two hundred lunatics.
Of the two medical members of the Commission, one (Mr. Wilkes)
agreed with the majority, and Dr. Corrigan dissented. That Mr. Wilkes
should sympathize with the Superintendents, and thus advocate the
claims of the order to which he had once belonged, was only what might
have been expected. Dr. Corrigan brought a mind perfectly unprejudiced
to the consideration of the subject, and not only dissented, but, impressed
with the great importance of the interests at stake, embodied his objec-
tions in a letter to Mr. Walpole, the then Secretary of State.
The Deputation could affirm positively, that this movement on the part
of the Superintendents was far from being general ; for there were some of
their body who declined taking part in it, acknowledging that they felt it
a great advantage to have within their reach the skill and experience of
men whose assistance, they were not ashamed to confess, they needed in
the difficulties inseparable from the diseases of the insane.
The Deputation assured Sir Robert Peel, that the Physicians had no
wish to ignore the professional status of the Superintendents ; on the
contrary, they willingly conceded it ; although, up to the present, the
Superintendents are not entitled, by the rules of the Privy Council, to
any position beyond that of managers.
Medical Superintendence of Asylums. 261
Without meaning to disparage the Superintendent*, the Deputation
tVlt hound to represent that they were, from being excluded from general
practice, unequal to the efficient discharge of i lie grave responsibilities to
which they aspired, viz., "the treatment of the inmates of asylums, hotli
aa regards their bodily health and mental diseas<
The Deputation was fully alive to the value of Resident Medical
Officers in Hospitals for the Insane; but they should he, as in Other
hospitals, subordinate t<> the Visiting Physicians, who should direct the
medical treatment in all cases of serious bodily disease.
In conclusion, the Deputation directed Sir Robert Peel's attention to
the following letter of Dr. Corrigan, whose opinions upon all subjects
connected with medicine are worthy of the highest respect : —
" Dublin, 4, Merrion-square, West, July 3, 1858.
" Sik, — In the Report of ' the Lunatic Asylums (Ireland) Commission,'
which has been forwarded to you, I have felt it incumbent on me, while
concurring in the other parts of the Report, to have my dissent recorded
on what appears to me a most important practical point. I v/as desirous,
and I made a request to that effect, that my reasons should be appended
to the Report, as, on consideration, I saw grounds to apprehend that no
future opportunity of stating them might' occur ; and I hoped to be able
to show that I had sufficient reasons for the view I took, it being, of
course, understood that the Commissioners, differing in opinion, should
also append any observations they might think proper. The majority of
the Board did not, however, consider that my request should be complied
with, and I therefore beg to forward the enclosed communication, con-
taining my reasons in support of my view, with a hope that you wrill (if
you see no impropriety in my request) have it laid before the House, or
published in whatever way you may see fit, so that the point at issue in
the Report may receive the fullest consideration. I would not take the
liberty of making this request, if I did not feel a very strong conviction
that the question is one of the utmost importance to the proper care and
protection of the most afflicted of our fellow-creatures. — I have, &c.
(Signed) "D. J. Corrigan.
•• Right Hon. Spencer H. Walpole, M.P., Secretary of State,
" Home Department, Whitehall, London."
" I am of opinion, as expressed in the body of the Report, that ' there
should be a Visiting Medical Officer attached (as heretofore) to each
asylum ; that his attendance should not be dependent on the discretion
either of the Resident Physician or of the Local Board, but that he should
visit the institution daily. That while the Resident Physician and
Manager should have general charge of the institution, and be responsible
for the treatment of the insane, as such, the duty of the Visiting Medical
1/ rintend . I uh
cer in their regard should I only t
[aired in consultation by the Resident Pbjsician, but that
\ itin ■ HedicaJ Officer should daily \i-it aU cases whatever confined to
lusion, or under restraint. Thai In- should see, with u little
delay a- p tssible, all rases of injury, accident, and childbirth, and record
rations on then as may appear requisite. That he should be
directly responsible for the treatment of the sick, as distinguished from
the mere insane. That in all if discharged patients, tin- certificate
of discharge should be signed by both Resident ami Visitu us;
and that, in all of death, the record <>f the illness and caUSC of death
should b I by both the Resident and Visiting Physicians.'
•■ For the following reasons, I consider it would be wrong to commit
the medical, surgical, and moral treatment of the inmates of a lunatic
lum, female as well as male, to the uncontrolled management of any
o\i<_' individual. If there be not a Visiting Physician, this would be the
state of each asylum; for we have it in evidence that Governors and
House Committees as a general rule do not inspect the asylums: nor
even, if they were inclined to do so, would they be capable of efficiently
fulfilling such a duty, so that, if there be not a Visiting Physician, whose
officv it would be to see all cases of illness, accident, injury, pregnancy,
and childbirth, as well as all cases subjected to seclusion or restraint,
there can, in my opinion, be no sufficient safeguard against cruelty, ill-
treatment, neglect, and even immorality. It must be remembered, that
the inmates of a lunatic asylum present no analogy to the inmates of any
other public institution. The inmates of gaols, workhouses, and hospitals
are sane, and can bring their complaints before visitors while in those
institutions, and will be listened to, or, on leaving, can have them in\
tigated ; while the poor creatures who are the inmates of a lunatic asylum
may be terrified into silence, incapable of stating their wrrongs or their
complaints, and perhaps may have their well-grounded assertions of past
ill-treatment considered as the mere delusions of their imagination. I do
not consider that any periodical inspection, at intervals more or 1
distant, will be a sufficient substitute for the daily inspection of a visiting
physician.
" I do not think it far-fetched to conceive the existence of abuses in a
lunatic asylum, evading detection for a considerable time, if there be no
officer daily visiting from without, and free from all connexion with
those resident in the asylum, who may be so implicated, that each may
be unwilling, or even afraid, to make a disclosure on the other, while the
lunatics aro all the time the sufferers. The following extract from the
last Report of the Commissioners of Lunacy in England will support my
argument (vide Eleventh Report of the Commissioners in Lunacy to the
Lord Chancellor, ordered by the House of Commons to be printed,
July 7th, 1857) :—
Medical Superintendence of Asylums. 263
" - The lodden emit which bad fonned the subject of inquiry wee that
..f a pauper lunatic, Daniel Dolley, 66 yaaW of :'.'-r,'< which took place in
the Surrey A-vlum OH the Hth of April Iftet, and of which notice was
transmitted by Mr. Bnape (Resident Manager and .Medical Superin-
tendent) to this (.llice on the 1 1th, as produced by dJBaafl of the lieart ;
such haying been the finding of a coroner's jury ;it an inquest, held on
I lie 12th by Mr. Carter, the coroner of West Surrey. On the day of the
inquest, however, a letter, dated the previous day, and addressed to the
Commlas ioncrs, not signed by name, but purporting to come from the
attendants of the ■Sylum, had reached the office, which led to the
suspicion that the Enquiry had been so conducted by Mr. Carter, as to
elicit none of the material circumstances attending the death.
On that occasion (the inquest), no questions had been asked, nor any
information given, but such as might seem to exhibit an ordinary
occurrence of sudden death The entire substance of Mr.
Snape's evidence was, that, having found the deceased violently excited
on the morning of the 9th, about half an hour previous to his death, he
prescribed a shower-bath That he found him dead half an
hour later ; and that, on subsequently making a post-mortem examination
of the body, he discovered enough to account for the death, sudden and
unexpected as it had been, in extensive disease of the heart.'
" The following are the facts that came out as to the old man's death,
on subsequent inquiry ; and I shall still give them in the words of the
Report, merely omitting unimportant parts : —
" ' On Mr. Snape's coming, in the course of his usual round of the wards,
into No. 3, and having it reported to him that Dolley had kicked another
patient, he called the old man by his name, and, heedless of his abuse,
told him to ' Come this way,' walking, himself, in the direction of the
shower-bath.'
" Barnett's (the attendant) evidence may be given in his own words : —
" < After I had him in, and the bar down, Mr. Snape says, ' Now pull
the string, Barnett ; keep him in half an hour.' .... Before Mr.
Snape left, however, he gave another instruction : ' Give him a good
dose of the light-coloured mixture ;' not restricting it by any condition
having reference to the strength or weakness of the patient, or to the
continuance or otherwise of his excitement He (Barnett)
gave Dolley, on leaving the bath, in compliance with the order, four
tablespoonfule of the mixture, containing two grains of tartarized
antimony Dolley remained in the bath twenty-eight
minutes, .... 'the water always pouring.' .... 'The
old man came out,' . . . ' and walked, assisted by Barnett, to the
chair by the lire.' " Here Barnett administered the tartar emetic'
Superintend
If an hour before the bath h<- was ' I. Light-hearted, and
dan Immediately after tin- hath he was ihivering. The witi
Pin a to state: '1 put his socks on ;' .... 'and, on
loot tin at tin- old man, I >aw hiin with hi- !.t««; drawn up. sitting
m the chair, with his head light back, hi- neaith open, and hi-
Unite tight, as though in a tit. He was carried to hed, hut I aiy
aatiye could be tried, he irai death'
■• It is only necessary t<> add to this detail, in reference t" Mr. Snape'i
report of the ease being death from 'extensive disease of the heart,' that
Mr. Hancock, Surgeon of Charing-CrOSS Hospital, and Mr.
Surgeon-in-Ordinary to the Queen, both examined the heart, and
observed no material disease, and nothing in it to occasion death.
On examination of the bath by two civil engineers, it appeared that I
gallons of water at a temperature of 45°, not many degrees above freezing,
must have been discharged uninterruptedly over the person of Dollej
he stood in the shower-hath, of which the construction was such as to
render, during its continuance, respiration more than ordinarily difficult.
" There is no Visiting Medical Officer attached to the Surrey Asylum.
Mr. Snaps had sole charge of the medical, surgical, and moral treatment
of the patients. The cruelty and false entry of the cause of death in the
above case would not have been left to the chance discovery of an
anonymous letter if there had been a Visiting Physician to that insti-
tution to have been examined on the inquest, whose duty it would have
been to have made himself acquainted with the previous circumstances of
the case, to have been present at the post-mortem^ and certified as to the
cause of death; and if a case of such cruelty had very nearly escaped dis-
covery, it is to be feared that minor cases of the exercise of bad temper
and tyranny, ill-treatment or neglect, may be of frequent occurrence,
ami yet for a long time escape detection. This case further shows
that a state of terrorism may exist to prevent any subordinate from
openly giving information; for not one of all the officers or numerous
attendants came forward on the inquest to expose the conduct of Mr.
Snape.
"In dealing with lunatic asylums and their defenceless inmates, it is
necessary to take into consideration, not how many cases of abuse have
been discovered, but to reflect on how many may be concealed. All the
Irish District Asylums, with the exception of the Cork Asylum, have
Visiting Medical Officers. In Cork there is no Visiting Physician. The
Resident Manager has the sole medical charge, calling in the Visiting
Surgeon only when he deems it necessary ; in fact, it is the system which
is recommended by the majority of the Commissioners. The circum-
stances that came out on evidence in that institution, appear to me to
ehow that that system is not one to be adopted. I can here only refer to
Medical Superintendence of Aeylunu
265
the minutes of the evidence generally, with tin- exception of that in
connexion with the examination of Mr. N. Barry.
"Mr. N. Barry had hern sent to the asylum under the Lord Lieuten-
ant's warrant, and bad been discharged cured. ( Pufl Appendix, Evidence
of Mr. Barry.) He came before as to complain of being ill-treated by
the keepers, of being beaten by them, of being confined t<> bed from the
injuries he received, of the. keepers being repeatedly dronkj of t ho
Etesidenl Physician refusing t" permit him to see the Visiting Surgeon
when confined to the infirmary, and of his also withholding Mr. Barry's
letters to bis solicitor, although the right of a lunatic to communicate
with his solicitor is protected by act of parliament. The Resident Phy-
sician, in reply to Mr. Harry's statements, asserted that, with the excep-
tion of the alienation about beating, which he stated in a written report
to have been 'grossly exaggerated and malicious' on Mr. Barry's part,
all his other statements were 'more fanciful than anything else;' but
that he was right as to one man bein£ drunk. On looking over the
minute-book, however, it appeared by a memorandum of a meeting of
the Board, on the loth January, that four of the servants were on that
day fined for being drunk, and that another was dismissed for bringing
in bottles, which, on examining her room, were found to contain whiskey,
and that this occurred during the period referred to by Mr. Barry, which
appears corroborative of his statements. The evidence of the Visiting
Surgeon would have been most desirable in this case, as to Mr. Barry's
alleged injuries, and his being sent to hospital in consequence, but it was
not available from the circumstance of its being left optional with the
Resident Manager to call on him in consultation ; and if this system
were to be generally adopted, it would happen that it would just be in
the cases in which it would be most necessary to have the evidence of a
third party that such evidence would not be forthcoming.
" As the treatment of insanity is. a mixed medical and moral treatment,
I consider it desirable that in cases requiring more than the ordinary
routine treatment, there should be at hand the advantage of the experience
of the two Medical Officers, each bringing his peculiar knowledge to
bear upon them, just as in cases partaking of a mixed medical and sur-
gical nature in hospital and private practice, patients under similar
circumstances enjoy a similar advantage. Moreover, I do not consider
that the Resident Physican or Manager, no matter how well educated he
may have been on his appointment to the care of an asylum, is, after a
little time, competent to treat medical or surgical diseases of a serious
nature. It is practice alone that keeps up this competency, and this he
Cannot retain ; for aii asylum cannot furnish him with sufficient practice
and he can have none out of doors. I do not think it necessary to ar^me
this at Length. No one would consider for himself or one of his family
the professional opinion of the Resident Physician of an asylum as of
I/, h ■ I s tp< i intendenc '■ i
equal rahie with that of the Practising Physician oi »n outside.
In the i insane, the peculiar p and observation,
that are only maintained by constant practice, are
than for the sane; for the lunatics may either conceal or not feel th<
tptomfl that will be described by the and hence the Phj
or Surgeon Is more thrown upon hk own powers of diagi
contradistinguished from symptoms*
-, in my opinion, another reason for having a Visiting
Physician of the neighbourhood in regular attendance at an asylum.
[am satisfied his visits afford a consolation to the friends outside, and
that it tends to lessen their reluctance to send their lunatic relative- into
SjO asylum, to know that they are -ecu by the Physician from without;
ami in the event of any ill-founded rumour- ever arising, of death- Of
sickness from ill-treatment or neglect, the assurance of the extern Phy-
sician to the contrary, will do more to reassure them than any assertion
coming from within the walls.
"The present rules for the regulation and definition of the dutii
Resident Physician and Manager, and of Visiting Physician, are very
defective, and hence much confusion has arisen. This was inevitable
from the rules of the Privy Council having been originally based on the
circumstances of the resident being a lay manager. In some of the
asylums this state still exists, while in others, the majority, medical
persons have been appointed residents, but still no general rules or
regulations have been drawn up. In some cases, merely verbal directions
have been given on the respective duties, in others none at all, the
Visiting and Resident Physicians arranging their duties by a private
reement ; but this confusion appears to me to prove only that some
new regulation is necessary, not that the present system is a bad
one.
" I have heard it as a reason for discontinuing the Visiting or Con-
sulting Physician, that collision- would occur between him and the
resident as to treatment; that injurious consequences would heme arise
to the patients, and in the management of the asylums ; and that the
pride of the Resident would feel hurt by receiving any advice from
another physician. I can attach no value whatever to what I believe to
be only exaggerated or imaginary evils. AVe do not find that such
collisions arise between the resident medical officers of our large hos-
pitals, and their visiting physicians and surgeons ; nor do we find that
such collisions take place in the consultation of daily and hourly occur-
rence in private practice. Nor do we find that physicians and surgeons,
possessed of common sense, ever object to receive professional aid in
consultation, and I do not see why such collisions should be more likely
to be apprehended in the intercourse between the medical attendants of
a lunatic asylum than in other instances. If any little jealousy or
Medical Superintendence of Asylums. ~li\l
bickering has occurred in any instance, it has been owing t<» the want of
rales, and would not rcmr under proper genera] regulations.
i* There appears to me to be, in addition, b very serious difficult in the
working of tlu> arrangement for the office of visiting or consulting
physician, as proposed by the majority of the Commissioners. He is to
be called in at 1 1 u* discretion of the Resident Physician ; but how is he to
be paid? It must cither lie by a sep.-irate lee for each visit, or by an
annual salary. In cither case the Resident Physician will be most
unpleasantly circumstanced. If the Visiting Physician is to be paid by
fees, then the Resident Physician, even for the most pressing cases, and
in which he conscientiously feels he requires the professional aid of
another, may be blamed by the Board of Governors for putting the
institution t<> expense, and even charged with incompetency. If the
Visiting Physician, on the other hand, be paid by salary, then he may
lind fault with the Resident for calling upon him too often, and, as he
may think, unnecessarily ; while the Board of Governors may blame the
Resident for not more often calling in the Visiting Medical Officer ; and
thus a state of bickering will be engendered between two officers, whose
mutual good understanding would be most desirable in the performance
of their duties.
(Signed) "D. J. Cokrigan, M.D.
" Office of Lunacy Commission, the Castle,
" Dublin, July 3, 1858."
/
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Pathology, and Cure, in Relation to
Curvatures, Paralysis, Epih-p-v, and va-
rious Deformities. By Ed. W Tuaooj
111* . ., &c. London Da
1861. Svo, pp. 155.
•J. A Guide to the Treatment of Dis-
- of the Skin ; with Suggestion! for
their Prerention. For the use of the
Student and Genera] Practitioner. 11-
Instrated by (uses. By Thoe. Hunt,
l l; C S., fcc. Fifth Edition. London:
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London : I'ieldson and Jary. ISo'l.
Pamphlet, pp. LO.
4. library of Practical Medicine. Pub-
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Medical Society, for the use of its 1'el-
lows. Vol. XXIII. Containing Placenta
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William Lead, M.D. Philadelphia: J.
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5. General and Medical Education. The
Introductory Lecture delivered at the
Queen's College, Birmingham. By John
Clay, Senior Prof, of Midwifery, &0.
London: Churchill. 1861. Svo, pp. "JS.
6. Amputation of the Cervu Uteri.
By J. Marion Sims, M.D., &C, &c.
Extracted from the Transactions of the
Medical Society of the State of New
York. 1861. Svo, pp. 16.
7. Papers relating to Quarantine ; com-
municated to the Board of Trade on the
3oth of July, 1861.
I >n the Successful Treatment of
Gonorrhoea and Gleet, without Copaiba.
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Royal Free Hospital, &c. London :
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9. Edinburgh Veterinary Keview. No.
XIX.
10. Influence of Tropical Climates in
producing the Acute Endemic Diseases
of Europeans, including Practical Obser-
vations on the Nature and Treatment of
their Chronic Sequeke, under the Influ-
ence of the Climate of Europe. By Sir
J. R. Martin, C.B., E.R.S., &c.,* &e.
Second Edition. London : Churchill.
1861. Svo, pp. 778.
11. Transactions of the Pathological
Society of London. Vol. XII. Session,
1860-61. Svo, pp. 256.
12. On Ovariotomy and its Results.
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6 Sul lore Tiattaniento. ! |
del Dottor Giovanni Polli. Milano,
ito, pp. 60.
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gli [poSOinti medieinali del Dottor-
\anni l'olli. Milano. Bvo, pp. 2
15. Eztrait des Memoirea
delle Malattie da Fermento Morbifioo a
del loro Trattamento at Baggio Parma-
cologico sui Solhti a gli Iposolfiti medi-
cinali. Par le Docteur Jean l'olli.
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16. Report of a Committee of the
Boston Society for Medical Improvement)
on the Alleged Dangers which Accompany
the Inhalation of the Vapour of Sul-
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17. Memoir of Baron Lam v, Suigeon
in Chief of the Grande Aiuiee. Erom
the 1'ivneh. London: Renshaw. L861.
Post Svo, pp. 256.
IS. Medical Climatology; or a Topo-
graphical and Meteorological Description
of the Localities Resorted to in Winter
and Summer by Invalids of Various
Classes, both at Home and Abroad, By EL
E. Scoresby- Jackson, M.D., &c. Lou-
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1 9. A Handbook of Forensic Medicine,
byJ. Caspar, M.D., &c, &c. Vol.1.
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Brome sur lTodure d'Aldehydene. "J.
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hyde. Extrait des Comptes Rendus des
Seances de l'Academie des Sciences. Tome
XLVlI. 3. Sur une Base Nouvelle ob-
tenue par l'Action de l'Ammoniaque sur le
Tribromure d'Allyle, Extrait des xVnnales
de Chimie et de Physique. 4. On the
Actions of Acids on Glycol. 5. Ueber
zwei neue Mcthodeu zur Bestinnnung des
Stickstoffs in organischen und unorgan-
ischen Verbindungen. 6. On the Syn-
thesis of Succinic and Pyrotartaric acids.
Erom Philosophical Transactions, 1S61.
By Maxwell Simpson, M.B., formerly
Lecturer on Chemistry in the Original
School of Medicine, Peter- street, Dublin.
22. The Principles and Practice of
Obstetrics. By Gunning S. Bedford,
A.M., M.D., &c. Illustrated by four
coloured lithographic plates, and 99 wood
engravings. New York: Wood; London:
Sampson, Low, and Son. 1861. Svo, pp.
731.
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269
28, ftfedioo*4 Ihirargioal Tranaaotiona.
VoL XI.1Y. London. L861. Bto, pp.
781.
84. Bradahaw'i Invalid Companion t"
the Continent, oompriaing General and
Medinl Notice* of the Principal Plaoei
of II csort, with Appended ( H.s( r\ :it i< >ns <»m
the Influence of Climate and Travelling,
and ftioteorologioa] Tablet. By £dwin
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don: W, J. Adams. L861. Fcap. 8vo,
pp. 110.
85. An [ntrodnotion to Mental Phil-
OtOphj "ii the Inductive .Method. By J.
I> Biorell, A.M., LL.D. London: Long-
man. 1 v''_'. Nvo, pp. 161.
26. A notice of Menton, Supplemen-
tary to Nice and its Climate. With
Remarks on the Influence of Climate on
Tuberculous Disease. By Edwin Lee,
M.D., &c. London : W. J. Adams.
1861. Fcap. 8vo, pp. 43.
27. On a case of Aortic Aneurism, in
which a Communication with the Pul-
monary Artery was Recognised During
Life by Means of Physical Diagnosis. By
\V. B. Wade, M.B., &c. 8vo. pp. 8.
(Reprint from Medico-Chirug. Trans.)
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28. General Outline of the Organiza-
tion of the Animal Kingdom and Manual
of Comparative Anatomy. By Thos.
Rymer Jones, F.R.S., &c. Third Edi-
tion, illustrated by 423 engravings. Lon-
don: J. Van Voorst. 8 vo, pp. 841.
29. A Manual of Psychological Medi-
cine, containing the History, Nosology,
Description, Statistics, Diagnosis, Path-
ology, and Treatment of Insanity, with
an Appendix of Cases. By J. C. Buck-
nill, M.D., &c, and D. H. Tuke, M.D.,
&c. Second Edition, enlarged and re-
vised. London: J. Churchill. 1862. 8vo,
pp. 600.
30. Pre'cis Iconographique des Maladies
Ve'ne'riennes. Par M. A. Cullerier, des-
sins d'apres nature, par M. LeVeiUe,
Gravures au burin sur acier. 2eme
Livraison. Paris: Librairie de Mequig-
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81. The Royal College of Physicians
and Surgeons under the Medical Act.
By J. Struthers M.D., &c. Edinburgh':
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51.
Clinical Beaaya By B. W. Rich-
ardson, M.D., &c. Asclepiad Vol. I.
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De la Byphilisation, Btat actuel
tatiatiqne. Par W. Boeek. Chris
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Svphilisations forsog, foretagne af
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ledniu o af & is balvhnndredaartfeat. Af
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38. Inversio vesica? urinaria*, og Luxa-
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39. Traite de la Radesyge (Syphilis
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41. Medical Education. A Discourse
Delivered at the Meath Hospital, by W.
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42. Observations on the Growth of the
Long Bones and of Stumps. By G. M.
Humphry, M.D., &c. (Reprint from
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43. Les Me"decins Morelistes, Code
Philosophique et Religieux, Extrait des
Ecrits des Me"decins, Anciens et Modernes;
Notamment des Docteurs Francais Con-
temporaires. Par Madame Woillez.
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44. Etudes sur l'Histoire Naturelle,
Par Camille Delvaille. Paris : G.
Bailliere. 1862. Fcap. 8vo, pp. 251.
45. The Blow-Pipe Vade Mecum. The
Blow-Pipe Characters of Minerals, from
the Original Observations of Aquilla
Smith, M.D., &c. Alphabetically arranged
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gate, 1S62. 8vo, pp. 65.
46. On the Immediate Treatment of
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ment of the " Stricture Dilator." By B.
Holt, F.R.C.S.,&c. London: Churchill.
1862. 8vo, pp. 57.
47. Clinical Surgery. The Surgery of
the Mouth, Pharynx, Abdomen, and
Rectum, including Hernia. By Thomas
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don : Churchill, 1861. 8vo, pp. 101.
18. The London and Provincial Medi-
cal IHreetory. inclusive of the Medical
Directories for Scotland and Ireland, and
/ / ; nge Jaw
the General Medical Register. London:
Churchill. 1 • • pp LO
tab JournaJ of Homoeopathy,
. i\ , January 1, 1
50. Atlai of Portrait! of Diaeaiei of the
Skin, [flailed hy the New Sydenham
Society. Second Fasiculus.
51. of tin; Hospital for the
i fcm< ill of Diseased of Children, fur
18(11. Dnblin.
< »n BOBD ruiinnent
Mortality in Karl .
By W. Muure, A.l;., M.l>, Ac. Dublin :
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NOTICES TO CORRESPONDENTS
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THE
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to supply ob with data for estimating the amount of moisture in the
air; and. in the more extensive establishments, the anemometers and
rain gauges appear to complete the entire collection of facts respecting
the .Mate of the atmosphere, according to our present mode of
observing.
\ I 'I. XXXIII., No. 66, \ .8 B
.
\ rtahahachnft :»ku*eo«
I . - •
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mhUi v ■ K C Doadm, I *.r. : •.. util
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THE
DUBLIN QUARTERLY JOURNAL
oi
MEDICAL SCIENCE.
MAY 1, 1862.
PART I.
ORIGINAL COMMUNICATIONS.
Art. IX. — On the Employment of a Heated Thermometer for the
Measurement of the Cooling Power of the Air on the Human Body.
By Jonathan OSBORNE, M.D., King's Professor of Materia
Medics ; &c., &c.
Tcc^oLjgU rovg aifyu)7F6vs ov roe. 7T(>ciy(*ocTcc ccXXcc rot mpi rav
7rpotypcCT&>v doyftxrx. — El'ICTETUS, 5.
PHYSICIANS often anxiously examine meteorological tables in order
•crtain flic localities best suited to their patients. There is no
want of such tables; and many of them constructed with gnat care
and elaboration. Within late years we have not only observations
thermometric and barometric, with their highest and lowest daily
readings, but those of the wet and dry bulb-thermometer, in order
ipply OS with data for estimating the amount of moisture in the
air; and. in the more extensive establishments, the anemometers and
rain gauges appear t<» complete the entire collection offacts respecting
the Btate of the atmosphere, according to our present mode of
oba rvi]
VOL. XXXIII., NO. 66, N. 8 B
Employmen r
When, however, ire vriah to learn firom such I he itate of
with reference to their actual influence on the human
encounter a deficiency which all have exp
which is often attempted to be supplied by an appeal to popular
ition, and by retorting to tl -ation of hot and cold, {<
*ed in common by the most barbarous as well as the most civili
classes of mankind. Thus, in some localities with a high thermo-
metric temperature, we are informed that invalid* complain of the
cold ; and in others, where the thermometer proclaims it to be cold,
the inhabitants find it to be warm. Vague and inaccurate as these
popular statements must be, yet, without them, no just estimate of*
climate can be formed. Within a short period a highly respectable
physician brought forward his thermometric observations as an
irrefragable testimony of the mild and genial climate of a certain
place on the western coast of Ireland, where even the trees are
stunted in their growth by the constant wind blowing from the
Atlantic. One such example of this kind is surely a sufficient proof
that up to the present time we are more dependent on our feelings
of cold and heat, imperfect though they may be, than on any
meteorological observations hitherto made, and that they are required
to enable us to form a judgment as to the cooling or heating qualities
of the air.
Several years ago, under a deep conviction that our thermometric
observations, as hitherto conducted, were inadequate to instruct the
physician in what he most desires to know respecting climate, I
brought before the British Association, at their first meeting in
Dublin, a proposal for using a heated thermometer. This was accom-
panied by several illustrations of the behaviour of such an instrument
under various circumstances, in order to prove its applicability to
every condition of climate or locality. The eminent persons at that
time assembled in the section expressed their approbation, and three
committees were appointed, viz., one in London, one in Edinburgh,
and one in Dublin, to investigate the subject. However, as I did
not feel called upon to bestow more labour on a subject which ought
to have no more interest for me than for others, it has continued to
be neglected up to the present time. Some years later, when the
meteorological survey of Ireland was undertaken, under the auspices
of the Royal Irish Academy, I suggested that observations with the
heated thermometer should be included among those to be made at
the various stations. It was recommended by some members of the
committee, whose names, were I to mention them, would at once
for tlw Meaiurtment of the Cooling Power of the Air, 275
enlist thfi confidence of the scientific world in \\> favour; but it was
considered by the majority to require too Enoch trouble on the part
of the observers, and was consequently abandoned.
Since its first introduction I have never yet been shaken in my
opinion of its value; and have subsequently made some changes in
order to render its use more intelligible, and, at the same time, to
facilitate its application to various practical purposes. The great
object has been to render the all-important agencies of heat, and
cold, and climate, subject to actual measurement, so that they may
be entirely, and without any exception or reserve, dealt with like
any of the other appliances of medical science.
The principle on which the use of the heated thermometer depends
is easy to be understood. The bulb being heated up to 90° Far.
represents the heat of the surface of the human body; when in
this state it is exposed to a cooler medium — whether air, or water,
or mixture of both, as moist air — and allowed to cool to 80° Far. ; the
time required for cooling these 10 degrees represents (inversely) the
cooling power exerted by that medium, whatever it may be, or
however applied. This cooling power is derived from other agencies
besides difference of temperature — as from radiation of the neigh-
bouring objects, conducting power of the surrounding medium, and
more especially from currents causing various proportions of it to
be brought into contact with the heated body within a given time.
Now these agencies have their combined results exhibited in the
degree of rapidity with which the cooling is effected. Placed, as we
are, in a medium, with few exceptions, always below 80°, we are
constantly undergoing a process of cooling. In our ordinary clothing
we feel just comfortable at 56° in-doors ; but when exposed to a
current of air, even at the same temperature, we feel cold in propor-
tion to the force of the current, or in proportion to the conducting
power imparted to it by increased moisture. Both these are agencies
of which the thermometer takes no notice. Its indications are
furnished by the contractions or expansions of a fluid, whether mer-
cury or spirit, which always maintains the same temperature as the
surrounding medium, and accommodates itself to these changes by
altering its own density in the same proportion. The living animal,
on the contrary, as always maintaining a temperature of its own,
and as constantly resisting cooling agencies, is not to be considered
as passively submitting, like the fluid of the thermometer in its
ordinary state. When heated to 90° Far. — that being nearly the
temperature of the surface of our bodies — in the rapidity with which
B 2
876 I > / ; loyment oj Then m
it i- cooled, depending on the intensity o\ the cooling influences, it
furnishes an index to theb combined effect. It i lot depid the
force of anj one of the cooling influence! tak 1\, but
the sum of them all acting simultaneously.
This accomplishes tin- great desideratum <>t' rendering the ther-
mometer practically useful. As the instrument thus heated becon
the representative of the heat at the Burface of the human body ; and
the rapidity with which it is cooled represents the energy of the
cooling forces; I venture to propose that, under this adaptation, it
should be called the animal-heat thermometer. The less the Dumber
of seconds in which it cools, the greater is the cooling power, and rice
versa; so that the greatest warmth is expressed by the greatest
number oi' seconds required for cooling down a given number of
degrees. The thermometer for this purpose is to be graduated only
from 90° to 80° Far. At each observation it must be heated up to
90°. This may be done by immersing the bulb in warm water;
after which it must be wiped. Or it may be heated in its tin case
over a spirit lamp. Another mode of heating it, which appears very
unscientific, but is very convenient when out of doors, is to hold the
bulb of the thermometer close to the neck of the observer, inside his
shirt collar, lor two or three minutes, when it may always be heated
to the required temperature, or even a few degrees above it.
For the animal-heat thermometer, the number of seconds during
which it cools these 10° forms the scale of measurement. The
number one commences when the instrument is plunged into water
at, or nearly at, freezing point; and for the other end of the scale,
when in calm air, at temperatures approaching 80° Far., the number
of seconds will amount to several hundred. At these high tern-
peratures it would be most convenient, and even become necessary,
to take only the five degrees from 90° to 85° Far. ; and in this case
the number of seconds would be much less than half, from the
rapidity of cooling being in a greatly increased ratio to the difference
of temperature.
A very important consideration is the choice of thermometers.
For this purpose they should be without any kind of frame, except
a hook at the top for convenience of suspension. I prefer the
spirit thermometer as being more easily seen, and as less rapid in its
descent than mercury, and the cylindrical bulb as being less liable
to be broken than the spherical bulb. In order to obtain uniformity
in the action of different thermometers, to be used by observers in
different localities, it will be necessary to place a number of them,
for the Measurement of the Cooling Cower <>f //,,■ Ait. 277
previously graduated at 80° ami 90°, in <'<>I<1 water and cold air of
certain assigned temperatures, and to -elect from these Mich afl cool
down :il what - 1 1 : 1 1 1 l.c lixed afl B Standard rate.
For example, the thermometer now used by me cools down the
10° in water at rest, temperature 46° Far., in 6"; and in water
at rest, temperature 65° Far., in 12". In water the cooling is too
rapid to secure accuracy in counting the seconds, and therefore must
not he depended on. The rate of cooling in air may be taken by
placing the thermometer in the middle of a cylindrical bottle of
certain dimensions, say two inches diameter, so as to guard it
against currents. If the thermometer which I now use be taken as
a standard, its rate of cooling from 90° to 80°, within this cylinder,
(a :1S follows:— At 40° it cooled in 122"; at 60° it cooled in 186".
If the instrument was not enclosed within the cylinder the results
would be very different and very uncertain, from the effect of cur-
rents of air, even in the most sheltered apartments, as will be
evident from experiments to be mentioned hereafter.
For counting the seconds a second watch may be used ; but as it
requires some practice to keep the eye both on the thermometer and
the dial at the same time, and especially at the moment of stopping,
the easiest mode is to use a string pendulum vibrating half seconds.
This is portable ; and the rod or ring to which it is attached may
be suspended any where within view of the observer, due care being
taken that it shall not produce a current of air so as to affect the
bulb of the thermometer.
The following observations are intended to illustrate the facts
exhibited by the heated thermometer: —
First. — It shoivs the conducting power of air or water, respecting
which the ordinary thermometer is absolutely silent.
The temperature of an apartment wanned with fire and gas was
54° Far. ; in it the animal-heat thermometer cooled from 90° to
80° Far. in 91". The same heated thermometer, in water of same
temperature, cooled the same amount in 8". Thus showing that
water at 54° Far. is nearly 12 times as cold as the air at the same
temperature — a fact conformable with our sensations on taking
a cold hath of the same temperature as the air, but of which the
ordinary thermometer takes no notice.
In a dosed room, temperature 1<) Far., it cooled in 71". In the
same room, same temperature, the bull) loosely covered with a piece
of damp woollen cloth, it cooled in 36". Thus showing the effect of
damp clothes, even in the house, to be as 2 to 1. This proportion
Db. Osb I mphyment of a i
mid, do doubt, be greatly augmented ou1 of <: ind hy expo-
sure to a breeze.
JOnd. — It shows the cooliny effects of currents in t) ling
media of air or wai
In water at rest, temperature 7()D Fur., it cooled in 24"; but
when agitated in the tame, in 1 ">". In this simple experiment uv
see the real limit to swimming. Great as are the muscular achieve-
ments in which some men excel their fellows, none have ever been
able to swim beyond a certain distance — such as that across the
Hellespont — because the application of fresh surfaces of water, even
of the ordinary temperature, cools the body beyond its powers of
supplying heat. I [ere we have the cooling as increased by pr< tgreflrion
compared with our remaining stationary in the water in the pro-
portion of 100° to 6*0°, which would be much greater at a lower
temperature.
In a room, temperature 57°, the animal-heat thermometer cooled
in 115". When blown on with a bellows, in the same room, it
cooled in 16". It is needless to say that the thermometer, in its
ordinary application, gives no note of this difference; the wind
blown from the bellows having the same temperature as the air of
the apartment, and yet the cold is nearly as 100 to 14. This cooling
effect of currents is illustrated by the punkah used in the East, and
by the ordinary fan. Even in a room, with all the windows and
doors shut, there are cooling effects of the internal currents to be
measured by this instrument. Thus, the animal-heat thermometer,
in a closed apartment, temperature 60°, cooled in 131". Placed in
the same apartment, in a cylindrical glass jar about two inches in
diameter, it cooled in 157"; showing the warmth in the one case to
that in the other as 83 to 100 — of wdiich the thermometer gives no
indication.
Third. — It shows the effects of windy that most important element of
climate, and which is entirely unheeded by the ordinary thermometer.
Kxposed to the open air, temperature 61°, it cooled in 45".
Exposed to the same air, but protected by the glass cylinder, it
cooled in 149" ; showing the warmth experienced in the one case to
be to that in the other as 30 to 100; and yet in our best thermo-
metric accounts of climates this difference is unnoticed, as if it did
not exist.
I have learned from a lady, once resident in St. Petersburgh, that
during the great severity of winter, when the thermometer is at
many degrees below zero, the drivers of public vehicles are bound
for tht' Measurement of like Cooling I'ower of the Air. 279
(o be al their stands ; hut if there ii a wind, even to :i small degree,
they may Btay at home, ii haying been ascertained that dangerous
mid even fatal effects resulted from such exposure. Similar obser-
fations arc recorded in the journals of our arctic voyagers.
This cooling effeci of the wind, which make- itself to be felt even
when blowing at a moderate temperature, has not hitherto been
attempted to be estimated — and it is improbable that it will ever be
accomplished in any other way than that now proposed. Even with
ipect to the anemometer, supposing that it could be rendered
applicable to this purpose, yet difficulties meet us in limine. Mr.
Grlaisher (Report on Meteorology, 1847) says that "we can speak
with no confidence as to the average strength of the wind, no two
observers having estimated the value upon the same scale."
Fourth. — It shows the refrigerating effect of air admitted into
apartments from open ivindows.
In a room without a fire, temperature 44°, it cooled in 72". In the
same room, within a foot of the window open a few inches, the night
being calm, and the external temperature being 34° Far., it cooled
in 32 " . In this observation the night was remarkably calm, and yet
the cooling effect produced was more than two to one, although the
difference of temperature, according to the ordinary thermometer,
was only that between 34 and 44.
On another night, the internal temperature being 51° and the
external 45°, the animal-heat thermometer, in the same apartment,
near the closed window, cooled in 100"; but when a small portion
of the window was open, so as to admit a blast from without blowing
in that direction, it cooled in 33" ; that is, the warmth which was
as 100 suddenly became as 33, a ratio which would be greatly
increased if the apartment had been at a high temperature ; and it
is in such cases that windows are most frequently opened for the
admission of air.a
* The cold air thus applied becomes indeed "t?te arrow that flyetk by day," and
signalises its visit not so much by present inconvenience as by those various inflam-
matory and often fatal disorders resulting from it, which are so well known to the
medical practitioner. In a long corridor at Sir Patrick Dun's Hospital, formerly left
exposed to a violent current of air from open doors at the end of it, and felt to be
inclement and dangerous even by those most reckless of cold, I believe it could be
proved that to stop in it for a stated number of hours would be attended with more
danger than to be present for the same space of time in any of the great battles fought
in Europe. In none of these have the killed and wounded amounted to more than
one-fourth of the armies engaged ; a proportion inferior to that of the fatal and
dangerous diseases certain to be produced by the blast in that corridor during the same
number of hours. The agency of cold as a cause of disease is apparent in the tables of
fgBORNi Employment Thm nu
h /' Imt degree the heat d<
j,lu mied by a cooling process from the > "> >
rushing towards the /■•
In front of a small screen opposite the fire the thermometer stood
at 61° Far., thr animaUheat thermometer cooled in L23". Behind
the -ana- Bcreen the thermometer stood at ~>1", tin- animaUh
thermometer cooled in 79". Now, in an apartment of tin- MUM
temperature, the animal-heat thermometer^ not mar tin- fire, cooled
in KM)". Thi- Bhows, that in the case of a man sitting opposite the
tin', warm as his shins may he, tlu- calves of his legs an- D01 Onlj
not warmed, but an- exposed to a cold above that of an ordinary
apartment of the same temperature in the proportion of LOO to 79.
Sixth. — It slioics the cold and heat of climates OS actually felt by
human beings-
The tables which I have kept to compare the animal-heat ther-
mometer with the ordinary thermometer, as a means of measuring
cold, prove the latter to represent only one out of several agencies
engaged: hence, while sometimes a certain conformity between
them is observable, vet the animal-heat thermometer take- a much
wider range, shows a greater sensibility, and always has this dis-
tinctive peculiarity, that it represents the temperature as judged of
by the feelings of the observer. This conformity between the
results of the animal-heat thermometer and our feelings is confirmed
no less on taking averages than in individual observations. Thus,
on comparing two tables — one of 20 days" observations, taken in
September, outside a window with a north aspect, but in some
degree sheltered from that wind, and the other table of 24 days'
observations, taken inside the apartment, which was always without
a tire, the heat of the outside was to that of the inside, according to
the ordinary thermometer, as 90 to 100, but according to the
animal-heat thermometer, as 54 to 100. Now, that this latter
number expresses the truth must be evident to any one who has
ever enjoyed the shelter of a house as contrasted with exposure to
the open air.
When we find in Professor Dove's isothermic lines that in the
month of January the temperature of the centre of Ireland is the
mortality during the months of winter as compared with those of summer. Even during
the latter season the same agency is in active operation. From an estimate which I
made of the patients, in summer, at Sir P. Dun's, most of them chronic, and all serious
cases, above one-half were to be distinctly referred to cold variously applied, but in
the greatest number to currents of air.
Db. Mi EtNBi on Fractures of the Skull. 281
Same m that of Montpellier or Marseilles, we see :i statement so
contrary to the experience of living men and women as to pro-
claim Loudly tli*1 want of .-nine other means for ascertaining the
effects of climates besides those hitherto in use. It u under the
conviction that this mode of observation supplies the defeel that it
is submitted to tin- medical profession as m<>~t immediately suited for
their purposes.
The apparatus is so simple, the method of using it bo easy,
and it> results SO exactly accordant wit h the effects produced on the
sensible surface of the human body, that by it the one instrument
ins to present us with an epitome of all that we want to know
from all the instruments now used in meteorology: hence, then,
Long as this proposal has been neglected, I cannot refrain from
attributing it to the imperfeel manner in which it has been brought
forward; and I still hope that, sooner or later, it may attract the
notice of those who shall have the opportunities of testing its utility
and practical importance.
Art. X. — On the Statistics of the Mortality of Fractures of the
Skull; Effects of Operation, fyc, fyc* By Henry Murney,
M.D., Surgeon to Belfast General Hospital; President Belfast
Clinical and Pathological Society; formerly Demonstrator of
Anatomy Queen's College, &c, &c.
I have frequently noticed there is a tendency to class all fractures
of the skull together, and to look upon the patient's prospect as
little short of hopeless. Serious as the mortality is, I did not think
an examination of statistics would show so many sufferers rescued
from death.
I would here observe that, as a rule, I look with great caution on
statistical tables, knowing how frequently cases are classed together
because of some trifling point of resemblance, although they may
differ in most important particulars ; and also, that it is much more
likely a man would publish a successful than a fetal case, not that
any de.-ire to mislead or give a false idea of the mortality of a
disease might exist; but when, from the serious character of the
affection, it Was expected the tendency would be to death, a sense of
* Read before the Belfast Clinical and Pathological Society.
Di Mi i. Fractures of tJu Skull
a, perhaps n Larking one of pride, that, contrary to all
anticipations, recovery ensued, might tempt him to place on i I
that which probably he would not have done if the progBOtifl I
been verified. Grave objections, no doubt ; but, on the other hand, I
may say, for some time past, our Medical Journali have contain
lords of all the most seriou . with operations performed, in
the London and principal Provincial Hospitals in England, ire
thus likely to obtain an account of all unsuccessful as well as suc-
cessful oases, and will be enabled to approximate the mortality
many injuries not yet precisely defined. I would add my belief
that, from the fatal character of fractures of the skull, surgeons
hesitate less about the publication of th than in many other
affections requiring interference. These reasons I consider are
sufficient to warrant a greater degree of confidence than is usually
reposed in statistical tables, and I make use of them as giving by
figures an approach to the mortality, effects of operation, Ac., Ac.,
and some other particulars in this class of affection.
I have records of several cases of fractures of the head which
have come under my notice, I shall take the liberty of referring to
a few of them where I find they illustrate portions of the subject.
My information is not so accurate on some points as I could wish :
for instance, in fracture of the base, the reporter frequently mentions
that fact without specifying the part of the skull involved ; and in
injury of the superior region of the head, the calvaria is named
without specifying the bone or bones injured.
I have taken a period of 10 years, from 1851 to 1860, inclusive,
and have tabulated the cases of fractures of the skull to the number
of 253, which appear in the following Journals: — Times and
Gazette; Lancet; Dublin Medical Press; Dublin Hospital Gazette}
EdinburglL Monthly Journal; Dublin Quarterly; Guys Hospital
Reports; and the Trans. Belfast Clin, § Path. Soc. I have also ex-
amined Braithwaite s Retrospect, and the British and Foreign Medico
Chirurgical Review. I had not access to other Journals. Twenty-
five cases were treated by practitioners not attached to public
institutions ; all the others were contributed by the attendants on
the large metropolitan and provincial institutions, or by medical
officers in the public service.
Of course I shall follow the usual division of the subject, viz. : —
Fractures involving the calvaria or lateral parts of the head, and
fractures of the base ; and first of the former : — In addition to cases I
have treated myself, I have the particulars of 187. In 84 of these
Db. Mn;\i:v on Fraotwre* of the Skull. 283
the fracture was situated in one <>f the parietal bones; in 57 tlic
frontal; in 9 the occipital; and in 87, two bones of the calvaria or
lateral regions of the head were implicated, Of the precise part of
the Bkoll-oap wits not specified.
The mortality in these several localities was as follows: — most
serious of the last mentioned — out of 37 cases, 22 died; then in
fractures of the occiput — of 9 cases, 5 died; next we have injury to
the frontal hone — of 57, 25 died, and one remained under treat-
ment. Fractures of the parietal bones were most numerous and
least fatal, as of 84 cases, 34 died, and one remained under treat-
ment. As a summary we have 80 deaths; 99 recoveries; and two
undisposed of, in a total of 187 cases, being 46 per cent, of deaths.
A question has occasionally arisen, which are the most fatal frac-
tures of the superior region of the head? The above shows that
injuries to the posterior region are most, and to the superior least
dangerous ; and that fractures of the frontal occupy the middle
place in danger as in frequency.
Of the 187 cases the bone was depressed in 149. Should the
bone be elevated in every such case? should elevation be performed
on the occurrence of reaction, whether symptoms of compression
are present or not? or wrould the prospect be more satisfactory by
delaying till well marked signs of pressure are exhibited ? does the
age of the patient modify in any way our opinion ?
On reference to some of the older writers, as Pott and O'Halloran,
we find that every case of fracture, with depression, was considered
fit for the trepan. In the introductory observations to his work on
injuries of the head, published in 1793, the latter writer lets us
know, in his quaint style, how frequently he was called on to per-
form this operation, he writes: — "I have had no less than four
fractured skulls to trepan on a May morning, and frequently one or
two. In the course of above thirty-five years practice, I may safely
affirm, because truly, that on an average, one month with another,
from three to four cases have fallen to my share, of either fractures,
concussions of the brain, or extravasations. va Again he av
"Every fracture with depression necessarily demands the operation;
and though some particular cases may be adduced, when nature has
aehow or other brought about the business of healing, yet it is
by no means to be trusted to; and the surgeon is inexcusable who
fails to attempt, at least to propose and press it. Simple fractures
* Introduction, p. ">.
1 >k Mt RNE1 on I dl
of tin- cranium, witli depression, vrhen relieved on 1 1 * * - spot, or in
the space of two or three days, almost always terminate happily.
la the course of more than 200 accidents of tin- simple kind, I
cannot recollect a failure in a single instance.*1
'* Fractures without depression do not demand operation.*'*
Putt considers ;ill depressed fractures require operation; and nearly
all undepressed, also require tin- interference of the surgeon. He
perforation is absolutely necessary in seven oases out of
ten, of simple undepressed fractures of the skull. Let as for a
moment inquire why it i> so. The reasons for trepanning in thu
uv, first, the immediate relief of present symptoms arising
from pressure of extravasated fluid; or second, the discharge of
matter formed between the skull and dura mater, in consequence of
intiamniation; or third, the prevention of such mischief as experi-
enoe has shown, may, most probably, be expected from sneh kind of
violence ottered to the last mentioned membrane. These are the
only reasons that can be given for perforating the skull in the case
of an undepressed fracture; and very good and very justifiable
reasons they are, but not drawn from the fracture.""
In another place he Bays, kk I have no doubt that although by
establishing it as a general rule, to perforate in all cases, some few
would now and then be subject to the operation, who might have
done very well without it; yet, by the same practice, many a
valuable life would be preserved, which must inevitably be lost
without it, there being no degree of comparison between the good
to be derived from it when used early as a preventative, and what
may be expected if it be deferred till an inflammation of the dura
mater, and a symptomatic fever make it necessary."0
I find elevation of depressed bone was practised in 124 of the
cases I have tabulated, of these 60 died; (52 recovered; and '1
remained under treatment ; as nearly as possible the deaths were
50 per cent.
In 25 cases oi' fracture with depression, no operation was per-
formed. On analysis of the symptoms of those who recovered —
one had profound insensibility ; another was insensible and con-
vulsed; another had partial paralysis; the remainder were partially
insensible, or had threatened intiamniation in the head. Of those
who died the symptoms recorded are : — insensibility in one ; para-
lysis in another ; epileptic fits in a third ; (I use the expressions of
a Introduction, p. 31. b Vol. I., p. 104.
c Page 111.
Dr. .Mi i;m;v on Fractures of the Skull. 285
the reporters,) 7 died; is recovered: being a mortality of lv*
per cent.
*So///'' interesting Cases of Fracture of the Calvaria with I )<j>r< ~/i<>n.
have oome under my observation in hospital: —
A lad L6 yean of age, while engaged at work in one of the
Bhip yards, received a blow on the side of the head from :i heavy
piece of timber which had fallen a height of l(> or 1- feet; when
broughl to hospital we were informed he had vomited a large
quantity of blood; he laboured under collapse first, then concus-
sion; on oareful examination of the head (there was no seal}) wound,)
a fissure extended from the left parietal protuberance forwards for
about one and a half inch, bifurcated, producing the shape of the
letter Y ; the piece <if bone between the limbs of the letter, and
also, one margin of the fissure, in its posterior part, were depressed,
I would say rather more than the thickness of a half-crown. The
symptoms of concussion yielded after a time, and were followed by
cerebral irritation, and inflammation of a not very intense form.
When convalescent I felt dissatisfied with his stolid stupid manner,
but learned from his friends he was of a sulky disposition, and that
his mind and character were as before the accident. The treatment
adopted was cold applied to the head, mercury in small doses,
until the constitutional effect was produced, and when necessary,
purgatives.
In this case, from the vomiting of blood, I feared more serious
mischief than the fissure of a small portion of bone. The possibili-
ties of fractured base, or of injury to the liver, or some important
abdominal organ, suggested themselves; but when hours passed by
and full reaction was established without its recurrence, my attention
was fully turned to the concussion ; as it subsided from the depres-
sion of bone, I looked for the appearance of symptoms of compres-
sion— had such manifested themselves, I w^ould have cut down and
raised the bone.
A few days after the admission of the last, a boy, aged 13 years,
came under treatment. Two evenings previously, while seeking
fu]- a ball, lie had fallen from a man's shoulders and alighted on his
head; he i- reported to have been insensible for a short time, and
on recovery to have vomited repeatedly, and complained of pain in
the pari injured, with general headache and sickness of stomach.
( )n admission the head was shaved, no wound or abrasion was
visible, but a fissure of the skull, a- in the other case, was felt
extending from the left parietal prot uheranee forwards almost to the
Di Fracture of the Skull.
interior bolder of the hunt-; the upper margin of thii ••■
at the stent us in th<
1 pieced him on low diel m alteram
mercury, and kept him in hospital for a time.
Here we have one of those must infrequent oases — a grave injury
followed by most trifling constitutional disturbance; in fact, from
the time he came under my care he was well — all headache, &c, &&,
had passed off. My treatment was merely precautionary.
Again, about a week later, a fine boy, about eight years old.
brought to hospital — a log of timber had fallen on him, fracturing
the right forearm very severely, and causing a wound which com-
menced at the right frontal protuberance and stretched upwards
and backwards about four and a-half inches in length ; the scalp
was separated to a considerable extent, and a fracture, parallel to the
wound, occupied fully three inches of the frontal and a small portion
of the parietal bones ; there was depression to fully the thickness of
the skidl. In the unavoidable absence of my colleague on duty, I
saw him about an hour after admission. Bodily warmth was then
restored, his pulse and respiration were slow ; pupils dilated, unin-
fluenced by light; he lay quietly, head resting on the right (the
injured) side; when turned on the left side he gave a fretful cry and
endeavoured to replace it; by sharp speaking or pinching he could
be partially aroused — give a monosyllabic answer, and then sink
back into insensibility. The house surgeon informed me, half an
hour before my visit he could be roused with much greater facility,
when he gave his name, residence, &0., &c. That I might have an
opportunity of noting the increase of the coma, I deferred operative
interference for an hour, when I returned and examined him, and
was satisfied the insensibility was greater than before.
I then had him removed to the theatre for the purpose of opera-
tion; immediately before commencing, I again essayed to arouse
him, when suddenly he opened his eyes and answered quite collect-
edly, although slowly and rather stupidly. Under these circum-
stances I did not deem it necessary to raise the depressed bone.
The boy passed to the care of my colleague ; he laboured under
concussion for a time, and gradually recovered. He was discharged
in seven weeks.
This was to me a most interesting case ; had the profound insen-
sibility, which was twice so marked, continued, my treatment would
have been elevation of the bone with Hey's saw, if possible, if not,
by the trephine first, then the saw. The occurrence of insensibility,
Dk. MUBNBT OH Fractures of the Skull. 287
followed by a state from which he could be Moused, I believe, was
due to cerebral congestion, for, after severe injury the circulation ii
embarrassed and imperfectly performed; and, [have several times
noticed, although not BO well marked afl in thifl ease, the insensibility
sometimes more, Bometimea less profound, without any apparent
cause.
Ten months ago, B boy, L6 years of age, fell a height of 12 feet
in the hold of a .-hip on Queens Island, he alighted on the posterior
part of hifl vertex. I was iii the hospital on his admission, and was
informed that he was insensible for a period of about 10 minutes
after the accident, but from the time he was placed in the ferry
boat until his arrival here, he was perfectly collected. There was
a wound one and a-half inch long, situated over the upper part of
the occipital bone; almost at the summit of that bone a V shaped
fracture was seen, the point directed upwards ; the limbs were each
about one inch long ; the bone was depressed fully the thickness of
two half-crowrns ; he merely laboured under collapse, and wras
quite astonished when I ordered him to bed. The wound healed
up, and he was discharged in a month.
I saw him six months afterwards, he had not experienced the
slightest bad effects from the fracture.
This is another example of a most serious injury without the
appearance of a single bad effect — in fact, so well did he feel, I had
considerable difficulty in keeping him in hospital for a reasonable
time.
Is the danger to the patient increased by cutting down to make
an examination merely of the site of fracture — by, in fact, rendering
the fracture which wTas simple, compound? Most surgeons are
opposed to this treatment, Sir Astley Cooper, in his forcible lan-
guage, says, " the man who wrould do so should be cut for the
simples." Mr. Guthrie and others do not consider the patient's
danger is in any way increased by it.
I believe the principal advantage to be attained by it i3, that we
can ascertain more accurately the extent to which the cranium may
be fissured, and the amount of depression of the outer table; also,
if death of a piece of bone is about to take place wre are made
_rnizant of the fact at an early period by its altered appearance.
Although I would not practice it heedlessly, or without due consi-
deration, I should have no hesitation in cutting down, provided I
w;b uncertain as to the extent or amount of the depression of bone.
Of fractures without depression we have reports of 3# cases, of
Db Mi km I on I 'H-
which cumber 2 subjected to operation and L3 were not
the former 1 > died, 1- of thi lied, 8 red.
Among those subjected to operation, we fa of paralysis;
convulsed or with epileptiform lit-; 1 insensible;
>f compression; 3 of encephalic inflammation; and, what I con-
sider Btrange, 5 are marked as labouring under very Blight symp-
toms or none at all. Those not submitted to operation Buffered
from slight concussion, collapse, effects of shock, &a, &c. On.
recovery, had epileptic lit-.
In December, 1858, 1 brought before the notice of the Belfast
Clinical and Pathological Society, some cases of fracture of the
skull. One was a patient with fissure of the frontal bone. In
giving a brief account of his case, I stated, he laboured under
paralysis which gradually became general. Under treatment this
slowly passed off, and he was discharged from hospital quite
restored. Twelve months after, this man came under the care of
one of my colleagues, he had fallen into a vat of boiling ley in a
bleaching establishment. He told me he had enjoyed excellent
health since his dismissal; he had not suffered from headache, loss
of power, or any effect of his injury. In a few days after his
second admission he was attacked with tetanus, and died. 1 made
an examination of the head and removed the portion of the calvaria
which had been fractured, and which was completely united. The
dura mater was most intimately adherent to the bone in the
vicinity of the fractured part. The brain, &C., &C., were perfectly
normal.
A man, aged 22, had the upper part of his occipital bone frac-
tured by a heavy piece of iron falling on him, from a height of 12
or 11 feel When admitted he laboured under the ordinary symp-
toms of collapse; then well marked concussion. The fissure of the
bone could be readily detected at the bottom of an extensive wound.
There was no depression. In a month he was discharged from
hospital perfectly well. The case was an average one, without the
appearance of a single peculiar or anomalous symptom.
Thirty-four cases with depressed bone, although not labouring
under symptoms of compression, were operated on; of these, 22
recovered, 12 died. As many of the contributors do not mention
the symptoms (if any) which existed before operation, I have no
doubt, this series should be much greater. I have, however, merely
tabulated those in which the writer distinctly records the absence
of compression.
DR. Miknkv on Fractures of ike Skull. 28(J
I must confess my inability to understand the indication for the
use of the trephine or saw, where the report states the patient was
"sensible" or had no symptoms of compression. And, although I
find this practice lias been followed by some surgeons, I would not
pursue it, therefore, cannot commend it. I consider, at all times,
even in the hands of the most skilful, the use of the trephine must
expose the patient to considerable risk of encephalic inflammation,
and, that we are not justified in operating as a mere precautionary
measure, hut only in those cases, in which, from symptoms of com-
pression, we have reason to believe there is pressure on the brain
which may be relieved by interference.
Then- may be an exception to this rule, as occurs frequently in
military practice, a bullet producing what might be styled an in-
dented or stellate fracture; or in civil practice, a blow from the
sharp angle of a brick or slate, driving in the outer table and break-
ing the inner to a greater extent. Here we might expect pressure
on the brain or more extensive laceration of the membranes than
the slightly depressed condition of the outer table would indicate;
in such a case the appearance of less urgent symptoms, as convulsive
twitchings, epileptiform seizures, would be a sufficient warrantry
for the use of the trephine.
I may here appropriately refer to the question of the frangibility
of the tables of the skull. For many years my anatomical ex-
perience made me look with considerable doubt on the generally re-
ceived opinion, that the inner table is so much more easily fractured
than the outer. I often observed, if great violence be applied to a
skull-cap, the tables would be fractured to about the same extent.
In 1858, in a most valuable series of lectures, delivered in the
College of Surgeons, England, Mr. Prescott Hewett, not only
noticed this, but carried his observations further, he found where
violence is applied from within outwards, the outer table is usually
injured more extensively than the inner — if from without inwards,
the reverse ; where great force is used, both "will be broken to about
the same extent. On reading his remarks I tried these experiments
repeatedly, and believe his statements are correct. If, then, an
individual has fallen from a great height, alighting on his head, or
ha- received a fracture in some other way, from great violence, I
would anticipate the tables of his skull would be broken to the
same, or nearly the same extent, but, if a less force were applied to
a .-mall surface, 1 would dread splintering of the inner table.
Another question of interest is that of injury to the brain.
VOL. XXXIII.. NO. 66, N. S. C
990 Dh Ml B / 'dt
We all know the prosped is much bri m
merely depressed without hi. the dura . and injury
that membrane i- less fatal than wl. snc of th<
- torn, and possibly protruding from the wound. Borne
the most experienced surgical writers look upon this latter form of
injury a* almost necessarily fatal — the mortality i- \ ery largo and
\et many recover 1 have made a distinction between protrusion
of the brain and hernia cerebri, as it is at times called, on the one
hand, and simple wound or laceration on the other. Where wound
of 1 >rain has terminated in hernia, 1 have placed the ease under the
former head.
Of eases styled protrusion or hernia, there were 85 reported — 17
died, 18 recovered. Of wound or laceration, 27 cases — 18 died,
9 recovered; total, <>2 cases, with 35 deaths. Of these, 9 had more
or less of paralysis or convulsive twitchings; 7 symptoms of inflam-
mation of varying degrees of intensity; 9 compression, the majority
well marked, although some were not very profound. Then we
have concussion, collapse, and shock; several described as not
labouring under any symptoms; and some, in which the reporter
mentions many of the leading features, but does not state this
particular.
On looking at the mortality as it occurred at the different periods
of life, we find up to the age of 10 years, inclusive, there were 24
oases with 9 deaths; between 10 and 20, 49 fractures, with 1(5 of a
mortality; from 30 to 40, 86 cases, 48 fatal; and from 40 to GO,
24 with 10 deaths; two had not terminated when their report^
appeared.
1 do not consider it necessary to give an analysis of the plans
of treatment pursued. In a considerable proportion indeed, the
writers seem to have considered the indications 80 obvious, as not
to have recorded it at length. I would merely observe, venesection
was practised in 24 cases only. A marked contrast to the custom
of the older writers, and also to the injunctions of many within a
very recent period. Tartrate of antimony also seemed to be at a
discount, for I find it was used in three instances only. The pre-
parations of mercury were most generally employed, in some, merely
as purgatives, in a considerable number until the constitutional
effect was produced.
I would briefly sum up my views of fractures of the calvaria.
The most dangerous are those of the occipital ; the frontal next in
order ; the parietal least so.
Dr. M i n m ; y on Fractures of the Skull. 2 9 1
The mortality in fissure of the calvaria and depressed fracture is
nearly equal, considering all the cases. Bu1 take all the cases,
whether depressed or not. in which operation was performed, the
death rate was 50 per cent. All the cases where no operation was
performed, the percentage was about 34; or if we contrast those
eases in which there was depression but no operation, the mortality
was 28 per cent. ; with those also depressed and operated on without
any symptoms, the deaths were 36 percent. These facts must, I
consider, point to the conclusion, that operative measures should
only be used as a dernier ressort.
The eases of fracture without depression subject to operation,
showred a mortality of 52 per cent. Similar cases not operated on,
presented 33 per cent, of deaths. In cases of injury to the brain,
the mortality was about 43 per cent. Operation is fully warranted
when the injury is of the indented class already referred to.
In simple fracture, where there exists a doubt as to the extent of
the depression, I consider the surgeon adds extremely little, if
anything, to the risk of his patient by cutting down. Fractures
are borne with greatest immunity in the first and second decennial
periods. The danger to life is greatly increased in the third and
fourth, and again diminished in the fifth and sixth periods. I have
given a brief report of six cases of fracture of the calvaria with
recovery in each. In two of these the occipital — in two the parie-
tal— and in one the frontal were broken — and in one case the
frontal and parietal were both involved.
I have examined the reports of 66 cases of fracture of the base of
the skull. Of this number, 46 died, 20 were restored; about 69
per cent., an enormous death rate.
When we consider the great injury inflicted on parts so nigh to
the most essential portions of the nervous system, generally them-
selves sufferers from laceration or extravasation, and the uncertainty
which surrounds the recognition of these fractures during life, we
need not feel surprise at the short list of authenticated recoveries.
In those injuries hitherto considered we had, generally, tangible
and frequently visual evidence of their existence. In the present
class, during life, in many cases we are dependent for our prognosis
on symptoms which bear no proportion to the amount of fracture
sustained.
As an illustration, I would mention the following: — Within
half an hour of the admission of the boy with compound fracture of
the frontal and parietal bones, whose case I have related just now,
c 2
iv> Db Mi rn i l / of the Skull
i;tn, a. dso admitted i" hospital. \V" lii 1* - en
white-washing a house, <m a ladder about 20 feet high, a ludden
gust of wind precipitated him to the ground. Waen 1 nw him
about halt' an hour after admission, the surface was *"(jl, not oold;
be was perfectly collected; described how he had been engaged
before his fall; said he was insensible until shortly before his admi
eion; complained of pain across the temples. 1 noticed In: a
somewhat (a little) deaf; I asked was this the result of hi^ injui
he stated he had been deaf for many years — he had hied from the
right ear; but when I visited him within an hour of the accident
the hemorrhage had ceased, and there was a little dried encrusted
blood in the meatus externus.
Immediately after Leaving the bed, the house surgeon, in conver-
sation, suggested the existence of fracture of the base. My reply
was, it may be present, but if we have not an opportunity of exami-
nation we are not warranted in placing the case on record as one of
this injury.
This, with the other patient, passed to the care of my colleague
on his return to town. Frequently, when in the ward, I spoke to
the man; his mind was quite clear; he many times complained of
being deprived of his snuff box. The only circumstance which
attracted my attention was, he always lay on his back, and com-
plained of pain in his head if the nurse turned him on his side.
Until three days before his death, when he had symptoms of enceph-
alic inflammation, his mind was perfectly clear. Death occurred
ten days after admission.
I was not present at the post mortem, but was informed the
brain showed evidence of inflammation, and a fracture passed
through the right petrous bone, without involving the tympanum.
Now, I consider the absence of all head symptoms fully war-
ranted the opinion I expressed. The small quantity of blood which
flowed from the ear was of no value as a diagnostic, and the trifling
complaints of the patient might readily be caused by contusion.
I consider these two cases are worthy of being placed on record.
First, a sailor, 20 years of age, was admitted on 16th June, 1859.
W hile intoxicated he had fallen into the hold of his vessel, a height
of 12 or 14 feet, alighting on his head, and receiving a fracture on
the left side of his forehead from the sharp angle of a brick. The
fissured condition of the bone was visible at the bottom of an exten-
sive scalp wound, it stretched down to the supra orbital foramen,
and was of a t shape. The amount of insensibility was only partial,
Dr. MniM.v on Fractures of the Skull. 293
as he could tell his oame and age. BSa breathing was natural;
pulse 60; skin cool; on being lei alone be turned ofF to sleep
immediately. There were two small contused wounds on the Left
side of the face, one beneath the outer, tlie other heneath the inner
canthus; tor some hours continuous bleeding poured from these
wounds, followed, tor 24 hours, l>y copious weeping of serum.
There was considerable extravasation of blood behind the hit ocu-
lar conjunctiva, and the eye-lids were very much ecchymosed.
From this I diagnosed that the fracture, which was traced to the
supra orbital foramen, extensively involved the roof of the orbit.
I also considered the serum was arachnoidean which had passed
behind the ball, and made its way out by these wounds. On the
L8th, he had well marked symptoms of inflammation of the enceph-
alon; on the 21st, he had paralysis of the right side; he died on
the 25th — nine days from the injury. Insensibility was almost
complete after the first day.
I made a post mortem 12J hours after death. A large collection
of pus occupied the cavity of the arachnoid anterior to the left
hemisphere ; the arachnoid, especially in the neighbourhood of the
superior longitudinal sinus, was thickened and opaque; general
vascularity of the pia mater. On removing the brain, two clots,
each about the size of a shilling, were found, one on the roof of the
left orbit, the other in the middle fossa of the left side ; the brain
substance was normal in consistence, but highly vascular in all
parts, both cortical and medullary. The fracture in the calvaria
was more extensive on the inner than the outer table, without
depression, extending from below the left frontal eminence to the
margin of the orbit at the supra orbital foramen, in length, say
one and three-quarters inch; a similar fissure extended across the
top of this, at right angles, producing a T shape. In the base the
fracture stretched backwards, from the supra orbital foramen
through the roof of the orbit, completely breaking away a piece of
bone, nearly circular in shape, of the size of a shilling, rather inter-
nal to the centre of the orbital roof; this could be readily removed
by the forceps ; the continuation of the fracture extended from the
left towards the right side, through the olivary process and body of
the sphenoid bone, into the right side of the basilar portion of the
occipital, terminating half-inch anterior to the foramen magnum.
None of the other cavities were examined.
The extravasation beneath the conjunctiva enabled me to express
the opinion that the fracture extensively involved the roof of the
Db .Mi R ull
i-il.it The weeping of serum also pointed to fracture of fch* bf
1 had never witnessed it from this ntuation, nor do 1 recoil
having Been it recorded — I think it must be infrequent.
Tli ; somewhat similar: —On lltli - lasl
r, a man, 19 yean of age, fell from ;i scaffold 20 feet high,
alighting on his head. On admission he had bleeding from the
left ear and nose; he had also extravasation of blood beneath the
left ocular conjunctiva; he had Bymptoms of collapse first; thru
concussion; during tin- (lav he several timee vomited blood. As the
effects of the concussion passed off in the evening and early pan
the night, he was not only able to answer questions, l»ut manifested
curiosity as to where he was; how the accident occurred, &c, (S
This continued till within an hour of his death, which took place
lo^ hours after the accident. On examination, two fractures ex-
tended from the left frontal eminence downwards; one in front of
the external angular process, the other behind it; the brain was,
considerably congested, but was not lacerated or injured in any
part ; a small extravasated spot was on the most prominent portion
of the middle lobe of the left Bide; another over the superior vermi-
form process of the cerebellum; and a third on the upper surface of
the tentorium, near the right perpendicular semi-circular canal; the
brain substance was healthy.
There were two fractures in the roof of the orbit — one at its fore,
the other at its back part; both were connected with the li — ure
which stretched down the forehead; two also ran in the middle
fossa and terminated at the foramen ovale. Here the bleeding from
the ear and nose, with the vomiting of blood, pointed to the exist-
ence of fracture of the base; the extravasation behind the conjunc-
tiva, to injury of the orbital roof.
In the former case, the fracture stretched into each of the three
foS88B, in this the anterior and middle were involved.
Two other instances of extensive tract ore of the base came under
my notice1. One, an elderly man, was knocked down in the street by
a blow from the shaft of a car, he lived five days. On post mortem
at least one ounce of blood lay between the dura mater and the
skull-cap ; there were three clots on the surface of the brain, and
there was laceration of the grey matter on that portion of the
middle lobe which occupies the middle fossa ; the calvaria was most
extensively broken, and the anterior and middle fossa) fractured.
The other, also an elderly man, had fallen down the cabin stairs of
a steam boat, a height of about 12 feet; he lived 24 hours. On
Dr. Mubnsi on Fracturu of the Skull 295
post mortem the condition of the brain and membranes was much
the same as just described; there was do fracture oi the calvaria;
in the base the middle fossa was extensively broken, and the Lesser
wing of the sphenoid chipped off. I do not give tin; detail.- — as
neither of these eases presented features of much interest, hut place
them on record for future statistical inquirers.
From the accounts of the jtost martini examinations, the following
were the situations of the fractures: — Of the middle fossa alone
there were 1 1 cases ; of the anterior 10; of the posterior 2; of the
anterior and middle 4; of the posterior and middle 9 ; one of th<
had separation of the coronal suture. There were 5 cases of frac-
ture running into each of the three fossae; three of these had, in
addition, separation of the coronal suture. There were 5 cases in
which the precise locality is not described. On analysis of the fatal
cases, we may fairly exclude the following, when considering the
per centage of mortality. First, a case of fracture of middle and
posterior fossae, with fracture of some of the lumbar vertebrae;
second, fracture of the anterior fossa, and of the seventh cervical
vetebra ; third, fracture of middle and posterior fossae, with fracture
of several ribs and other injuries.
In such instances the serious injuries mentioned would of them-
selves suffice to cause fatal issue.
Again we have unusual, and I may say, necessarily fatal cases,
such as a piece of nail-rod penetrating the roof of the orbit, lacerat-
ing the brain, and causing copious hemorrhage by rupture of the
anterior cerebral artery.
The extremity of a walking-cane passing through the nostril,
perforating the ethmoid and sphenoid bones, and impacted in the
lower part of the brain.
Brass ferrule of an umbrella perforating the roof of the orbit and
impacted in the brain — and a piece of tobacco pipe lodged in the
same locality. The last three were only discovered on post mortem.
In all, 7 to be deducted from the number of 46 deaths, which would
leave 39. Add to these the 5 cases I have now recorded. This
would leave the mortality as already stated. I have brought for-
ward some of, to me, the most interesting matters connected with
193 fractures of the calvaria, and 71 fractures of the base of the
skull. In all. 264 cases. Many of the matters I have only touched
upon would. I know, supply ample material for valuable papers.
I )u John Hi obi *' Honrital Rst
Ai:i \1 // pital B By Job ! D Senior
Physician to the Mater Misericordiae Hospital.
Casi I '/ ilignant Distau of the Cecum, and Fatal Obstruction
the Bowels.
Awi; Nkli.w. :ui unmarried woman, aged 32, was admitted into
hospital on i Ith October, complaining of constipation of the bowels,
which resisted the action of medicine for the previous 10 OI 12
days, accompanied by vomiting, loss of appetite, and general pi<
tration. She was very low and desponding; having a small weak
pulse, and complained of pain in the abdomen. She told us her
stomach was deranged for some time; that she suffered much, of
late, from flatulent distention of the bowels and eructation of air ;
and that, although she took a quantity of medicine, her bowels,
habitually costive, were not moved for the last 10 days.
The tongue was clean, moist, and firm; the lips and cheeks were
remarkably florid ; the skin cool ; the urine natural ; in fact there
was a complete absence of fever. The pulse was small, weak, but
not very frequent — only 80 in the minute.
The abdomen was full, resonant on percussion in the umbilical
region, but not tender to the touch. She could bear pressure over
every part of it; and the most careful examination tailed in dis-
covering anything abnormal. The stomach was, however, very
irritable, and almost everything taken was quickly rejected; never-
theless we indulged in the hope that nothing more serious existed
than a temporary obstruction from accumulated feces in some portion
of the canal ; and the comparative mildness of the symptoms did not
tend to discourage such an impression.
After her admission, a mixture containing a saline purgative was
ordered to be taken every third hour until the bowels were moved ; at
the same time small quantities of ice were given to allay the vomiting ;
and lifjht nourishment was directed as soon as the stomach became
tolerant of food. The medicine acted with partial success, and two
or three small fecal discharges were obtained, rather fluid, but
natural in colour, to the great relief of the patient. The vomiting
was allayed, and she appeared better; but in a few days all the
previous symptoms reappeared ; the vomiting returned ; and the
pain was increased, and now located in the right iliac region. She
described it as being very severe, and coming on in paroxysms ; but
Dr. .John HUGHES' Hospital Reports. 297
not materially aggravated by pressure; and there was no fever.
Again a most careful examination was made, but no hernial or other
tumour could be discovered.
The rectum was explored, but no hemorrhoidal or other tumour
existed; and the long tube passed readily into the gut, proving
there was no stricture there.
The appearance of the abdomen, however, was very peculiar. It
was rather flat , knotty, and uneven, presenting a scries of inequalities.
The form of the intestines could be seen, apparently knotted and
twisted together, and they felt full of fecal matter, which a strong
and continuous vermicular action tried to force onwards without
success.
It was quite plain a most serious obstruction did exist somewhere,
and the question came to be discussed — "What was its nature ?"
That it was not of an inflammatory character was evident from the
absence of constitutional disturbance ; but whether it arose from the
pressure of a tumour upon the intestinal tube, from cancer of the
intestine itself, or from introsusception, we could not determine.
Fearing, however, there might possibly be some local inflammation,
however slight, I determined to give my patient the benefit of the
doubt, and ordered mercury with opium, internally, and counter-
irritation. Some transient relief followed ; but no medicine could
be persevered in, as the stomach was so irritable everything was
rejected almost as soon as it was taken.
For some days she continued in a state of alternate ease and
suffering, and without any evacuation from the bowels, although
they could be readily seen and felt loaded with their contents, and
striving to force a passage onwards. Even the enemata, which
were often repeated, brought away no fecal matter.
On the 2nd November — nine days after her admission — she felt
more depressed than usual, and said her stomach was very sick, and had
been so during the previous night. While she was answering my
inquiries vomiting occurred, and a large quantity of fluid feces
(certainly more than a pint) was expelled through the mouth.
Every one present recognised the peculiar odour of fecal discharges,
and so did the patient herself; for while expressing her great relief
1)\ the occurrence, she complained of the manner in which it was
accomplished. During a few days after this she was easier, and
appeared to rally. She took some nourishing broths, and the
stomach was quiet.
But the amendment was only temporary. The vomiting and pain
Dj Jons Hi ..in.- //
irned irith greater violence than before, and sympton I phoid
peritonitis set in. The abdomen became yerj tender to the touch,
all tj\rr The tongue wai dry and black; the i*ul
jeptible; delirium B6l in, and tin- patient k> rapidlj aank t!
imagined a rupture of the intestine ami extravasation into the
peritoneum had taken place, M I result of the violent and i-oiitiiiu
effort* to get rid of its contents. Such, however, did not happen,
ae iraa afterwards shown.
During this woman's illness, in the hospital, her ease excited a
I'uod deal of interest — more especially after the fecal VOmiti]
occurred; and Borne of my colleagues kindly saw her, with qp
during the last days of her life. Every known cause likely to pro
duee obstruction of the bowels was discussed; but the weight of
opinion was against malignant disease, owing to the age, and par
tieularly the appearance of the patient
A post mortem examination was made 24 hours after death, and,
on exposing the abdominal cavity, we found the small intestine lull
and loaded with feculent matter; the peritoneum showed signs of
recent inflammation of a low character, and contained a small
quantity of sero-purulent fluid, somewhat resembling pea-soup, but
there were no adhesions. The intestine itself was of a dark red
colour, and its texture was readily broken through; but there \
u<> rupture of its coats, nor any extravasation of its contents within
the peritoneal -
On removing the intestines, we found the ilium, especially towards
its termination, very much enlarged — probably to three times its
natural size — and containing feces which assumed a firmer con-
sistence as we approached the cecum, where the obstruction was
situated. Here wre found the canal, quite impervious, and the ilio-
cecal valve surrounded by cancerous deposit, so as to block up the
tube, and prevent the passage of the contents of the bowels. The
stricture was so close that water poured into the intestine could not
pass freely. There were also small round cancerous spots, about the
size of a split pea, in the walls of the intestine, immediately near
the valve, and the lumbar glands were affected ; but beyond this
there was no appearance of cancer in any other part or organ.
Below the point of obstruction the large intestine was remarkably
narrowed in calibre, and contained no fecal matter ; but we found
in it a portion of the enema, which had penetrated as far as the
caput coli.
This case, interesting in many points of view, is peculiarly so
Ok. .John Hi mils' ffospital Reports. 299
because of the absence of those constitutional signs which announce
to us the existence of Organic disease, particularly cancer. No one
Who saw this patient, and beheld her florid Complexion and healthy
appearance, could imagine slie was labouring under a form of disease
almost invariably associated with the anemic condition and peculiarly
unhealthy aspect; and the only way I can account for the anomaly
is, that perhaps the disease was of recent origin, and had not existed
long enough to produce those changes so characteristic of cancer.
In a case, recorded by the late Dr. Todd, of a similar affection,
the patient, who suffered a long time, was remarkably pallid — so
nuieh so, he says, as to attract the attention of those who entered
the ward. And this anemic state existed although "the ordinary
functions of the body were properly carried on, the circulation
appeared healthy, there were no symptoms of dyspepsia, the bowels
acted freely, the kidneys secreted as in health, and the usual quantity
of urine was secreted ; no fault of the catamenial function existed
adequate to explain the anemic condition. There was no hemor-
rhage of any kind, nor any exposure to miasmata."
But this anemic appearance unaccounted for by any other cause,
was of itself sufficient to lead Dr. Todd to the conclusion that his
patient suffered from malignant or cancerous disease, although her
age was only 30. And the post mortem examination proved he was
quite right. It cannot be doubted that pallor of the surface is a
prominent sign of cancerous disease; and the opposite condition
in the present case is very singular, and probably only to be
accounted for by its brief duration, owing to the mode in wdiich the
functions of the alimentary tube were interrupted.
This blocking up of the canal, too, is by no means the ordinary
effect of cancer of the cecum ; for in Dr. Todd's patient, who was
under his observation many months, he says the bowels acted freely ;
and the examination, after death, showed there was a perfect free-
dom of transit for the intestinal contents through the cavity of the
cecum. The cecum was reduced in size, and the caput coli wras
almost obliterated, so that the channel between the ileo-cecal valve
(of which one lip still remained) and the ascending colon was
exceedingly short ; thus the action of the ilium was of itself sufficient
to propel the contents of the bowels into the colon, and any accu-
mulation was prevented. So, also, in a case reported, in the Med.
and Phys. Journal, by Dr. T. E. Beesley, the passage was larger
than is usual in health, notwithstanding a great thickening of the
parieties.
Db JOHH Hi OHEfi Hotpita ■' rt$.
ttremely difficult and obscure
In Dr i there was the peculiar anemic condition which
Led to the suspicion of malignant disease; andth I, besid
a tumour in the right iliac region, and severe lancinating pain in
that locality; but we had no anemia, no decided permanent pain,
and no perceptible tumour; for it can be easily understood how tl
distended intestines would prevent its being felt had it existed
But in tact the Cancer had not attained a dze Bufficient to make it
perceptible, and consequently we possessed no data on which to base
a satisfactory diagnosis as to the cause of the obstruction.
It was singular, indeed, how little febrile disturbance was present
in this case, and how a condition of almost perfect ease and relief
alternated with paroxysms of suffering — a relief which alwa
succeeded vomiting; and so decided, that we were beginning to
think the case was about to assume a chronic form, and that the
contents of the bowels might be evacuated through the stomach, as
sometimes happens in cases of obstruction. This belief was strongly
increased after the large fecal vomiting which occurred some days
before death, and which was followed by so much relief. We know
how wonderfully, in some cases, the system accommodates itself to
defecation by the mouth. And every one is familiar with the case
detailed by Dr. Crampton, in the Dublin Hospital Reports, of a
young lady who had obstinate constipation and stercoraceous vomit-
ing for several years.
It may be inquired if the operation for artificial anus should not
have been tried in this case?
I believe the question could not, with any propriety, be enter-
tained, inasmuch as we could not ascertain the seat or nature of the
obstruction ; and, moreover, Ave had presumptive evidence it did not
arise from any impediment in the large intestine, as the rectum tube
and enemata passed readily into it.
The fecal vomiting in this case was a remarkable phenomenon.
Whenever that event occurs from an inversion of the peristaltic
action of the intestine, it is stated that in such cases the pressure of
the fluids above the ileo-cecal valve and that below it being about
equal, the valve becomes flaccid, and an intermixture of fluids takes
place, and thus we have fecal vomiting.
But I apprehend the explanation is not satisfactory in this case ;
for it will be remembered the fecal vomiting did not occur till some
days before death, and at a time when we were perfectly satisfied
the large intestine was completely emptied by frequent enemata.
Db. John Hughes1 Hospital Reports. 301
I know it is the generally received opinion that the intestinal con-
tents do not become fecal until after they have passed the ileo-cecal
valve; and I have beard snrgeonfl more than doubt the occurrence
of true fecal vomiting in Strangulated hernia, because it is the small
intestine which is commonly constricted. But it is quite certain,
nevertheless, that true fecal vomiting occurred in this instance, and
true feces was found above the valve after death. It occurred to
me that probably disease modified the functions of the two portions
of tlit" canal; and, under the circumstances, the small intestine
assumed the functions of the large in the obstructed state of the
canal ; or, possibly, that physiologists have not as yet determined
with certainty what portion of the intestinal glandular apparatus
eliminates that peculiar matter which gives to feces its characteristic
odour.
Case II. — Diabetes Mellitus — Saccharine Treatment of.
The saccharine plan of treating diabetes originated, I believe, in
France, and so far back as 1845. Bouchardat gave saccharine
fruits in diabetes, and bread made from gluten. Andral and Piorry
tried a similar treatment, with some success. And the practice has
been recently adopted in England, by Dr. Budd, of Bristol, who
has published some cases (two, I think) in which he says the most
marked amendment followed the use of sugar. Others have also
recorded cases ; but they do not exhibit so favourable a result as
those of Dr. Budd. It would appear, however, that some practi-
tioners who tried this plan have found it beneficial. Their patients
grew fat upon it ; and even this effect, in a disease where wasting
is so prominent a symptom, is a very desirable result. They say,
besides, that the practice is not an irrational one ; for Bernard has
shown that sugar taken into the stomach, in its passage through
the liver, is converted into an emulsive substance, which tends to
fatten patients ; and he has also proved experimentally, and Andral
and others practically, that sugar is secreted and found in the
circulation in diabetes, whether the individual be fed upon nitro-
genous or amylaceous substances : consequently our old-established
plan of dietetics in this disease, with all its restrictions, is useless.
Dr. Budd, one of its earliest advocates in England, says he gives
sugar in diabetes on the principle of supplying to the system the
particular element which is running to waste, and the loss of which
appears to be the principal cause of the damage sustained by the
l)ic John lit i. in- // y it
bution as the disease advances. On all tb ben, it
has t I that the laccharine treatment of dialx
worthy of a trial.
Amongst the many theories propounded concerning this intract-
able disease, modern researches incline to the opinion that the II
is the organ in fault — an idea long since entertained by Dr. Prout
Experiments by Bernard and Pavey tend to show that there is
always present in the liver, located in the hepatic cells in con-
siderable abundance, a substance which one calls the "glucogenic
matter" of the liver, the other "hepatine;" that this substance is,
with great facility, by a process allied to fermentation, converted
into sugar; but that it seems to have the power, whilst located in
the tissues of the living and healthy liver, to resist the transforma-
tion. In certain unnatural conditions, however, as well as after
death, this power is at an end, and the blood becomes surcharged
with saccharine principle.
If this be true, it would appear that the diabetic condition depends
upon some functional derangement of the liver, which converts
alimentary substances into this glucogenic matter in greater abun-
dance than natural, and allows it to mix with the blood in large
quantity, when it immediately becomes converted into sugar, and
as such passes off with the urine.
I am not sure, even assuming all this to be correct, whether we
are in a better position to decide upon the exact nature of this
disease. Probably, however, it is to physiology we shall have to
look, in the end, for a solution of this difficult question ; for patho-
logy is strangely barren of results in this disease; so much so that
it is doubtful whether the presence of sugar in the system either
necessarily depends upon, or produces, visible organic lesion of any
particular organ. When organic diseases do exist, they are looked
upon as merely concurrent affections.
However, it is not my intention to discuss the nature of diabetes
mellitus ; I merely wish to give a brief account of how this sac-
charine plan of treatment turned out in my hands, after a trial of
more than four months.
Four cases of diabetes mellitus came under my care in hospital,
almost simultaneously.
The first was a man named Thomas Ryan, aged 37, who had been
diabetic for 13 months before admission, and had been under treatment
for his disease during the greater part of that time. On admission
he was voiding, daily, eight pints of urine, specific gravity 1049,
Db. JOHN Hughes' Hospital Reports. 303
and containing 22 grains of sugar in each ounce. lie complained
6f great thirst, languor, and debility j the skin and mucous membrane
Were dry; the bowels confined; and all the usual symptoms of
diabetes were present.
1 treated this man with Dover's powder and the vapour bath, for
a fortnight, when he left the hospital relieved in respect to the
condition of the skin and mucous membrane; his thirst was abated,
and the skin was somewhat moist ; the quantity of urine varied with
the amount of fluid drunk, but its condition was unaltered. He
thought he was growing weak, and wished to go home. He told
me his father had a complaint similar to his own.
This man returned on the 18th January, and was then voiding
10 pints of urine daily, of a specific gravity 1041, 24 grains of sugar
in each ounce. He said he drank a large quantity of beer, one day,
at home, and was not as well since. I now determined to put him
on the saccharine treatment, and ordered him six ounces of barley
sugar daily ; diet of fresh meat, with green vegetables and bread ;
also a moderate quantity of lime-water and milk. He continued
this plan steadily for three weeks ; and at the end of that period his
condition was, to a certain extent, improved. The quantity of
urine passed was seven pints, the specific gravity 1041 ; each ounce
contained 24 grains of sugar ; and he gained two pounds in weight.
The skin was somewhat moist, thirst abated. He was again anxious
to return home, and left the hospital.
The second case was a man, aged 40; but as he was not in
hospital more than a week, and was treated with sudorifics (Dover's
Powder) alone, and almost an exclusively animal diet — I will only
refer to his case. In fact, he would not submit to the abstinence
from fluids, and the variety of food which I enjoined. He left
without any apparent change. There was one fact connected with
him of interest — he told us his father had the same ailment he was
labouring under, and died of it.
The next patient was a man aged 32 (John O'Neill), who suffered
from the complaint for 18 months before admission. On the 3rd
January he was voiding 15 pints of urine, of a specific gravity
1043, 18 grain- of sugar to the ounce. He was very thin, and had
all the symptoms of diabetes in an aggravated form. He was treated
with sugar and a mixed diet, like the former patient ; and at the end
<•(' six weeks his urine was reduced in quantity to sLx pints — the specific
gravity remaining the same. All the other symptoms were greatly
relieved, and he felt himself much better and stronger ; in fact so
Db JOHS I It UHBfi //
w.ll th. a be irai anxious t»» go and resume hU former employment
(thai of a shopman). Vt-t, on weighing him, we found he had I
four pounds in weight since his admission, and his mine contained
in- of sugar to the ounce. We heard that ho since died of
phthisis.
The last and most interesting case is that of Henry M'Nee. He
was a married man, 30 years of age; tall, well-proportioned, and of
a very athletic frame. He was always temperate ; had no hereditary
predisposition to the disease, and attributes his illness to proru
perspirations and alternate chills while working as a railway
labourer. Five years ago, when employed in England, he first
noticed his disease, and was treated for it at the Manchester Infir-
mary. After four months stay in that institution, he left at his
own request, relieved sufficiently to resume his work, at which he
continued for 11 months before admission. At that time he
noticed the aggravation of his disorder, which set in with great
thirst, increased flow of urine, general weakness, and rapid lossof llesh.
On admission, all those symptoms had attained a great intensity,
lie said he was only the skeleton of his former self; for, when in
health, he weighed more than 14 stone, and now he did not reach
12; which surprised him, when he could eat so much — four times
his ordinary quantity — and he did not feel sick, only very weak.
He was voiding 10 quarts of urine in 24 hours, of specific gravity
1049, and was obliged to empty the bladder every hour. He
drinks about the same quantity of fluids within the same time.
His urine has an acid reaction, is free from albumen, and each ounce
contains 24 grains of sugar. As an evidence of his broken down
health we found a large, chronic, indolent ulcer over the right ex-
ternal ankle.
I was determined to give the saccharine treatment an uncom-
plicated trial in this case; and, after an aperient, I put the patient
on six ounces of sugar, daily, together with four ounces of treacle;
bread, meat, and green vegetables for diet; lime-water and milk
for drink — with an injunction to limit the amount as much as
possible.
At the end of a month he was somewhat improved. He had
gained two pounds in weight; his thirst and appetite were dimi-
nished ; the quantity of urine passed in 24 hours was reduced from
10 to 7 quarts ; the specific gravity ranged from 1043 to 1045 — 21)
grains of sugar to the ounce.
During the next month he had two attacks of sudden and violent
Dr. John Hi (.uis' Hospital Reports. "><>.">
sickucs.- of stomach, accompanied with constant vomiting and
cramps in the abdomen and Legs. He complained, i'<>r a few days,
of great nausea, and felt as if saturated with sugar; everything, he
said, tasted sweet. He was. at the same time, weak. The urine
was of a specific gravity of L044 — not lessened in quantity. The
ulcer of le^ was healed. The sugar treatment was discontinued.
After the lapse of a few days the sugar was again resumed; and
his condition, at the end of another month, was as follows: — His
weight, L2 stone 11 H>.; consequently he had gained nine pounds
since last report. His urine is reduced to three quarts in 24 hours;
and he is not disturbed more than once or twice to pass it during
the night. His skin is moist; his bowels are regular; he has gained
strength, for he is able to work at the force-pump of the hospital
for an hour without resting. The specific gravity of the urine is
1035-9, but it contains a greater amount of sugar than before.
According to Garrod's glucometer each ounce contains 40 grains
of sugar. His appetite and thirst have decreased ; the ulcer of the
leg has broken out again.
After four months stay, he left the hospital in the month of
May, and obtained employment as a porter, which obliged him to
carry considerable weights; he remained at this work for six
months, during which time I saw him occasionally ; but at the end
of that period he was completely prostrate, and sought relief in
another hospital. As the sequel of his case has been published, I
will add some extracts from the report: —
He was admitted into Dun's Hospital, under the care of Professor
Law, in the month of January, and was then voiding 16 pints of
urine in 24 hours — specific gravity 1042. On the 10th of February
the quantity of urine was 12 pints — specific gravity 1035-9, and
contained 8*750 grains of sugar, or about 45 \ grains to an ounce.
On the 8th of March the quantity of sugar was 39 grains to the
ounce, the amount voided being the same. On the 20th March the
quantity of sugar declined to 34 grains; and on the 8th May the
urine was reduced to 10 pints ; there were 38 grains of sugar in
each ounce.
He left the hospital in July ; but was again readmitted late in
October, in an advanced stage of phthisis; and on the 10th Novem-
ber the post-mortem examination showed extensive tubercular
disease in both lungs. " Both kidneys were very large ; one weighed
\'1\ ounce-, the other 11. Both were much congested, but
exhibited no trace of disease or deviation from their normal struc-
VOL. XXXIII., NO. 65, N. S. D
Mb. lln.i'K.L on Cellular Polypus oftk I.
tare. Th> li \ vi vrai perfectly normal in rise and appearance; and,
en examination, did not contain n trace of sugar. It
and to ohemioal analysis a specimen of a health} li\
It will be Been from these oaeef in irhich the saccharine treatment
has had a prottj fidr trial that, to Bay the least, it produced no p
manent improvement. The specific gravity of the urine mu not
altered, and in each instance its saccharine quality wa
Tie true the amount of urine voided within a given period iras con-
siderably diminished ; hut 1 think that result lb \ei\ much within
the control of the patient, exclusive of medicine. I mean, ofcour
it* be chucks his desire for fluids. The gain in weight and the
iiu strength may he more justly attributed to other can
than to the amount of sugar taken; and I am quite satisfied, ><> far
a- ni\ observation enables me to judge, that the saccharine tn
ment of diabetes is not entitled to the credit which its advocates
claim for it. All that can he said for it is, that it is vastly agn
able to patient.-, and i- not positively injurious, a- one might a
priori he inclined to suppose.
Aim. XII — On Cellular Polypus of the Ear. By J. (i IIii.dk.i .
F.K.C.S.I., Surgeon to the National Eye and Ear Infirmary.
THE class of aural polypi comprised under the term "cellular"
has not, until a comparatively recent period, been specially noticed
by writers on aural surgery. As such polypi differ essentially
from all other- occupying the external meatus of the ear; and, as
they require a totally different treatment, perhaps some remarks
concerning them may not he deemed wholly superfluous.
According to my own observation they occur most frequently
in persons of a weak anemic constitution, who are obliged to pass
most of their time in ill-ventilated rooms, or lead sedentary li\
They may occur almost at any time of life ; hut, as a general rule,
seldom make their appearance after 24 or 'I'd years of age. They
commence insidiously. The patient may have had a slight attack
of ear-ache, to which he may trace the commencement of the
tumour, or he may attribute it to an injury; in most cases, how-
ever, he knows nothing whatever of its existence until he acciden-
tally inserts his finger into the external meatus, and then detects
it. From the commencement of the growth it is almost always
Mi;. Hildige <>u Cellular Poly put of tin Ear.
accompanied by a Blighl discharge, which differs from thai produced
in chronic catarrhal inflammation of the dermoid meatui by its con-
taining floeeuli of nmCOUS like small particles of thread. a Little or
no pain accompanies this class of polypi, although a pricking sen*
sation is sometimes complained of; Imt this is generally 80 trifling
thai it causes little or no inconvenience to the patient.
According to some writers, these tumours arc most frequently
attached to the superior or posterior walls of the meatus ; and when
seated near the orifice, sometimes completely close it up. They are
soft and \ ielding to the touch ; and by using a very slight degree of
pressure can be reduced to nearly one half their size ; if the pressure
be continued for any length of time fainting and insensibility are
produced; so that in all probability it was this class of tumour
which ancient writersb described as having their origin in the brain.
The following case, recently under treatment at the National Eye
and Ear Infirmary, presented almost all the characteristics of the
cellular polypus, although the situation and size of the tumour
differed materially from the generality of such cases : —
George K., aged 22, clerk, a pale, unhealthy-looking young man.
He states, that six months previously he had an attack of ear-ache
in the right ear, which subsided after a few hours' duration, without
any particular treatment having been had recourse to. Ever since
that time he has been subject to a slight discharge from the ear,
with occasional shooting pains, and gradually increasing deafness.
About six weeks ago (December, 1861) he commenced to feel as if
his ear were plugged up by a foreign body ; which sensation con-
tinued increasing until he had become very deaf of that ear, and could
no longer introduce the top of his little finger into the orifice of the
meatus. His general health had lately become much impaired. On
examination the ear presented the following appearances: — The
orifice of the meatus was occupied by a large cone-shaped polypus
of a bright reddish colour, which filled up almost the entire calibre
of the passage. It was soft to the touch, and easily compressible.
I was somewhat alarmed, however, when, on attempting to push it
aside with the forceps, the patient became faint; and a moment or
afterwards he lay down on Ins back; which position he was
obliged to retain for several minutes, until his faintness had passed
away. The polypus was attached by a broad, thick pedicle to the
anterior wall of the meatus, about one-eighth of an inch from the
* VideToynbee on the Diseases of the Ear.
u Vide Fabrice de Hilden, Itard, &c.
D 2
Mi; llii.i-i... ellular Polypus of tA
orifice, the lining of which in iderablj c there
little or no discharge present, nor had there been any for leveral d
previously. The watch was beard two inches from the < The left
i- sympathetically affected, a buzzing noise being continually
heard in it; the hearing of it was, however, tolerably good
1 attempted to remove ■ portion of the tumour with the t but
was obliged to desist on account of the extreme feinting fits which the
slightest interference with it produced ; I therefore contented myself
by prescribing a solution of acetate ot zinc (a scruple to the (Mince)
to he applied three times daily to the polypus, the meatus to he
previously syringed out with luke- warm water. Four days after
the commencement of this treatment the polypus had slightly
diminished in si/e, had become of a greyish colour, and the discharge
had not returned; hearing remained in much about the same state,
although the patient fancied he could distinguish sounds more
dearly. Six days later the polypus had diminished so much that,
with a little difficulty, an examination of the membrana tympani
was made. It presented all the appearances of extreme congestion,
being almost purple in colour. The portion of the meatus in its
immediate neighbourhood was also much inflamed, and much nar-
rower than in the normal condition. I prescribed leeches, to be
applied to the orifice of the meatus, counter-irritation behind the
ear, and the lotion of acetate of zinc to be applied to the tumour as
before. Under this treatment the polypus rapidly disappeared, and
the hearing improved considerably; but, as the patient discontinued
his attendance at hospital before he had quite recovered, I was
unable to say whether any permanent alteration in the structure of
the tissues entering into the formation of the meatus and membrana
tympani had taken place or not.
This case differs materially from the generality of cellular polypoid
growths ; the result of the treatment, however, proved that it was
of this nature, inasmuch as astringent lotions have no effect what-
ever on the vascular or fibrous polypi which occur in the same
situation, while they remove, in a very short space of time, cellular
polypi.
Mr. Toyubee, in his work on the Diseases of the Ear, describes a
form of polypus of the external meatus, which he denominates
"globular cellular." He says: — "The third kind of polypus
developed in the external meatus is the globular cellular species. I
have thus named a growth which essentially differs from those
belonging to the preceding classes (*. e., vascular and fibro-gela-
Mi:. Bildige on Cellular Polypus of the Ear. 809
tinous). [t consists of a sfoigle globular mass, perfectly smooth on
the surface, and without any appearance of granulation It is con-
fined to the inner fourth or sixth <>f the meatus, from the upper part
ofwhioh it is usually developed, and it hangs down like a curtain,
wholly or partially concealing tin' membrana tympani. It is of a
deep rod colour, is softer than the ordinary cellular polypus, and
docs not generally attain a si/.c larger than a small pea. The growth
usually occurs in children, or in young persons; it is attended by a
mucous discharge, which is often very offensive; and the secretion,
like that from other forms of polypus, consists of epidermoid cells,
which give a milky appearance to the water after syringing; it also
contains fine threads of mucous. This kind of polypus may exist
for several years without producing any severe symptoms ; and it
has not hitherto been distinguished from the other varieties of
polypus. . . . The aural disease with which the globular
cellular polypus is most likely to be confounded is catarrhal inflam-
mation of the mucous membrane of the tympanum, since in some
cases of the latter the mucous membrane is of a deep red colour, and
so much tumefied that it projects into the meatus for a line or a line
and a half beyond the position occupied by the membrana tympani
previous to its destruction. On examining the growth by means of
the speculum and lamp it is not easy to determine which of the two
diseases is present. The examination of the discharge, however, is
sufficient to decide the question ; for, although in both affections
flocculi mucus is present, that accompanying the polypus is com-
posed of small thread-like particles, while that emanating from the
mucous membrane of the tympanum presents large irregular-shaped
masses, generally of a yellow colour. The history of the case will
also usually aid the surgeon in forming a diagnosis, as the globular-
cellular polypus ordinarily appears without the manifestation of any
very decided symptoms ; perhaps the appearance of the discharge is
the first indication of its existence ; whereas the affection of the
tympanum generally originates in an attack of acute inflammation,
and often arises during scarlet fever or measles."
With regard to the faintness and insensibility produced by
pressure on the tumour, the same writer remarks: — " These symp-
toms of cerebral irritation frequently cause great alarm to the patient
and his friends, and appear to be the result of pressure of the
polypus on the outer surface of the membrana tympani and chain of
ossicles, which causes a movement inwards towards the cavity of the
vestibule of the inner extremity of the chain, producing continuous
310 Mi; llii.nn.i-. on Cellular Polypus of tit I
i of the fluid of the vestibules. Th by
eful inspection of a specimen, prepared bj me foe that pnrpo
which n i> manifest that although there are fcwo articulate
between the long process of the malleus and the base of the Btap
yet the slightest movement inward of the pro* mallsi
causes the base of the stapes t<» be pressed inwards towards the
. itv of the vestibule, and, as has been already stated, pressure on
the contents of the vestibule appears to produce results very similar
to those of pressure on the brain. According to my own observa-
tions the former giv< to — first, a sensation of noia >ondly,
confusion of ideas; thirdly, giddiness and insensibility."
According to my own experience surgical interference is contra-
indicated in all polypi of this class where there is tendency to extreme
syncope produced by handling the tumour, as in th I have
just related. A highly inflammatory action frequently occurs after
such interference, not only in the polypus itself, hut also in the
dermoid meatus, thus rendering an affection, otherwise comparatively
harmless, one of a highly dangerous character, from which the most
serious results must be anticipated.
In all probability Itard alludes to this kind of polypus when he
states — speaking of polypi in general — that it is only after operative
attempts to remove it that injurious consequences — the least of
which is permanent deafness — generally occur. He also states,
however, that all the polypi which had come under his observation
appeared to be of the same nature, and suggested extraction as the
only means of removing them.
Long anterior to his time Fabrics de llilden (in 1G04) pointed
out the danger occasionally consecutive to extraction of aural
polvpi in general; and in one case quoted by Itard* the following
extraordinary precautions were taken by the first-named writer in
order to counteract any inflammatory symptoms that might arise
after the operation. The writer says: — " Le traitement de cette
maladie ayivnt etc fixe an retonr de la belle saison, on conmieni/a
vers la tin de Mars a purger la malade. Le surlendemain, applica-
tion des ventouses aux epanles, et le jour suivant application d'nn
seton a la nuque. On fit ensuite usage dune electuaire tonique,
d'apozemes depuratifs, interrompus, par des purgatifs, en meme
temps quon saupoudrait la tete avec une poudre astringente et
aromatic pie dont on garnissait chaque jour la suture coronale avec
* Traite des Maladies de l'Oreille et de l'Audition. Par J. W. G. Itard.
Db. WmiOT on Aeute Grangrens. 8] 1
I'attention dVnlevcr auparavaunt oeUe qu'on avait mise la vcillc.
Apivs oei mojeofl preparatoires on en vint ,:i ['operation." From
this it is obvious that the danger of operative interference with some
polypi of the ear was known to ancient writers on aural surgery,
(although the utility of the above preventive remedies may be
called in question); and it was most probably the surgical removal
of this class of polypi, which I have been attempting to describe,
which was attended with unfortunate results both to patient and
surgeon.
Art. XIII.— Observations on Acute Gangrene, resulting from
Compound Fracture of the Leg. By Samuel G. Wilmot, M.D.,
F.R.C.S.I., Surgeon to Steevens's Hospital, &c, &e.
Of the many evils following from compound fracture of the leg,
none demands a quicker perception, or power of keener penetration
on the part of the surgeon, than acute gangrene, especially that of
the areolar tissue — genuine constitutional gangrene. The signals
which give warning of the impending mischief are sometimes so
faint as to admit of their being readily overlooked, and it is often
not until the evidences are strongly pronounced that the surgeon
becomes aware of their full meaning and takes alarm. This disease
proves a foe as stealthy as it is deadly, seldom manifesting itself in
open action until it has overcome the vital forces, and left no
ground on which it can be attacked. To be able to recognise the
first dawning of premonitory symptoms ; to correctly interpret early
and imperfectly developed manifestations, and not to be misled by
phenomena, which, however formidable in appearance, are either
accidental complications, or only secondary results, and not imme-
diate tokens of the fundamental mischief, are absolute requirements,
if the surgeon is to be put on his guard in time, and be prepared
for an energetic and decisive line of conduct. Nothing but close
observation of a number of such cases can give this necessary
discriminating power.
Wc may divide acute gangrene from compound fracture into
three principal forms. First, inflammatory gangrene, that which
Dfifnlts from intensity of inflammatory action, or from pressure
exercised by the efl'used products of inflammation. Secondly,
diffused gangrene of the areolar tissue, the skin being primarily, at
312 1 >h. \V ii.mui on A*
not implicated or Dot i Thirdly , lie
He of the deep Areolar tissue, oommeneing around tin- broken
UlrlltS.
The two latter tonus are essentially constitutional, tin- di*
depending not on the de of violence which the tissue
Sustained — nut on an) f action in tin- part, but on the
ult of some cir,' or unsoundness of the constitution. To tl.
two form- 1 shall confine my remarks.
The first kind of constitutional gangrene — the diffused gangrene
of the areolar tissue — is comparatively easy of recognition, even in
the early Stage. The wound on the fourth day, instead of sup-
purating or exhibiting a tendency thereto, a — una- a Bloughy asp
and very quickly a doughy swelling arises around it, which SOOB
crepitates on pressure. The emphysema, preceded by doughy
tumefaction, rapidly extends to the knee, and there are few instances
in which it does not break through the temporary barrier set by
the knee-joint, and running along the course of the femoral vessels,
reach the groin. Indeed, I have never Been an instance in which
more or less crepitation could not be detected along the line of the
femoral vessels, and in very bad and rapidly fatal cases, if there be
not actual emphysema much above the groin, the peculiar doughy
tumefaction which precedes it is sure to be found over the same side
of the abdomen, as high as and even higher than the level of the
umbilicus, and passing round to the back.
The gangrene is essentially of the areolar tissue, and it may
engage the whole of this structure in the limb, or, as is usually the
Case, only or principally the subcutaneous portion. The skin, for
some extent around the wound, frequently dies, but this is no
necessary part of the gangrenous action, and never does the sloughing
of the integument exhibit the same extent or degree as is observed
in ordinary inflammatory gangrene, which involves both skin and
areolar tissue at one and the same time. The most striking appear-
ance presented by the limb — almost a characteristic feature of
diffused gangrene of the areolar tissue — is a peculiar mottled marbled
hue of the skin, especially of that in the vicinity of the wound.
The constitutional symptoms which correspond with the develop-
ment and spread of the local mischief, are equally formidable and
rapid in their course ; indeed, long before the disease has extended
to the abdomen, the patient becomes utterly prostrated, fatal signs
are manifested, and all hopes of saving his life cease. The rapid
succession of the local changes, and the readiness with which the
Db. WlLMOT on AouU fi>tngrene. 313
system yields as they advance, render it a matter of extreme
difficulty to resort to amputation with any prospect of success.
The spread of the local condition on the one hand, and the progress
of the general condition on the other, rarely leave a moment
available for operation.
Much confusion, and, consequently, uncertainty, in determining
the question of amputation in all forms of spreading gangrene, hare
been created by the fact that exactly opposite opinions have been
advocated by two equally eminent authorities — Mr. Pott and Baron
Larrey — the former laying it down as a law that amputation is
inadmissible, unless the gangrene has ceased to spread; the latter
inculcating the rule of operating, even though it be extending with
rapidity. Most civil surgeons have ranged themselves on the side
of Mr. Pott, while military surgeons have, almost invariably, been
governed by Baron Larrey's practice. My own experience leads
me to espouse Larrey's rather than Pott's view of the question.
Not to operate until the gangrene has been arrested, and the
fever has abated, is apparently a sound practice ; but where is the
case of acute traumatic gangrene, whatever its kind or form, in which
these two happy events ever occur ; if we wait in the vain hope of
seeing these expectations realised, we wait to see pass by the only
possible moment at which amputation can be satisfactorily performed.
To wait watching for the arrest of the gangrene, and, finding the
advanced stages of the disease rapidly supervening to rush to the
knife, is a course not to be justified, for it can never be attended
with successful results.
If amputation is to succeed, it must be performed above the knee
and in healthy structures, and the strength must not, as yet, have
been far prostrated. To cut through emphysematous structures,
and especially to operate when the pulse is irregular, or fluttering,
or intermittent; when there is hiccup or other evidences of ap-
proaching dissolution, is an act little short of homicide ; it is but to
add to the sufferer's miseries, and to precipitate his death. It is
true that cases are recorded by military surgeons in which, owing
to the disease having spread so high, it has become necessary, in the
operation, to carry the knife through gangrenous parts, and yet the
measure has been attended with success; but these, and all like
instances, are not, I feel convinced, examples of the special gangrene
to which I have been alluding.
It is not long since my colleague, Dr. Hamilton, was called on to
amputate in a case of gangrene of the arm, where there were
\V I1.M..1 M
tumefaction and crepitation beyond the shoulder-joint, and though
tin- parts out through were almost, if not altogether the
patient re d in the mosl ictory manner. But thk
i an example of gangrene arising from a mechanical —
extensive subfascial extravasation of blood, Leading to ea
tension, and consequent arrest of the circulation in the ti
Here, as also frequently occurs in the if ordinary inilamumtory
agrene, a tumefied and emphysematous condition of remote parts
resulted, on the one hand, from passive efiuaion of the serum the
consequence of congestion, — on the other, from the travelling of air
alone the cells of the areolar tissue from the structures undergoing
decomposition. The remote tissues themselves are, therefore, not
the seal of actual disease, and -are in consequence oapable of taking
on full reparative action after being divided by the knife.
The ease is, however, very different in the form of gangrene, the
subject of the present remarks. In it the tumefaction of the areolar
tissue, in parts ever so remote from the seat of fracture, is of that
peculiar doughy nature, which is an unerring indication that the
first step in the process of local death has been made, and the
emphysema, which quickly follows, is due to the generation of air
in that part of the tissue, and not to its transmission from the parts
below.
It follows, then, that in acute diffused gangrene of the areolar
tissue following compound fracture of the Leg, amputation cannot
be resorted to with any solid prospect of success, unless it be per-
formed above the knee, and before the parts there have participated
in the gangrenous action, and also before the vital powers have
Commenced to give way. To hit off this happy moment — this
pause in the storm so to speak — is not easy ; but, unfortunately,
u where we are able to avail ourselves of the desirable period,
amputation holds out a meagre chance for the patient. For the
gangrene is constitutional ; we, therefore, can have no pledge that
the disease will not attack the stump, and we have reason to fear
that the system will sink under the effort it is called on to make in
the endeavour to establish the necessary reparative action.
Yet amputation, when the proper period for its performance can
be seized, is not only a justifiable, but a desirable measure, since it
offers the only possible chance of safety to the patient.
The second kind of constitutional gangrene — limited gangrene of
the deep areolar tissue commencing around the broken fragments —
is that to which I wish more especially to direct attention, as it
I));. WiLMoTow Aeute Gangrem. S15
appears bo me either to be in great measure overlooked, or not to
be clearly distinguished from the form jusi described. Yet the two
examples differ not only in local character, hut in the mode of death,
and also as to the vcr.-ion to he given to t lie <pu>t ion of amputation.
It is in a ease of this disease, that the possession hy the BUTgeOD of
those qualities already alluded to is SO essential. The disca.-e
makes its progress so stealthily, though rapidly, and not until far
advanced causing any alarming disturbance of the system, or any
very broadly marked loeal change, that the unobservant or inex-
perienced practitioner may be completely deceived, and fail to
recognise the real state of the case before actual fatal symptoms are
pourtrayed. Death is produced by poisoning of the blood from
absorption of putrid serum, and this event is quite compatible with
a very limited extent of gangrene.
The earliest notice that this kind of gangrene has commenced is
given by the wound, on the third or fourth day from the receipt of
injury. The lips pout, are thick, and present a peculiar waxy
appearance, and along their margin a narrow vesication arises
There is no suppuration, and the parts would be perfectly dry, if it
were not for the escape of some fetid brown serum, which wells up
from between the broken fragments. This condition of the wound
is certain evidence that gangrene, of the areolar tissue around the
broken fragments, has set in. At this period there is but little
general disturbance ; the pulse ranges from 80 to 90, soft and full,
and the patient does not exhibit signs of much prostration; the
constitutional character, however, of the change that has com-
menced is shown by the jaundiced hue of the skin and conjunctiva,
which is always apparent, and the irritability of the stomach,
accompanied with sour eructations. If the patient has previously
been dyspeptic, these symptoms are apt to be ascribed to the old
disorder of the stomach, or to the free use of liquids, in which his
thirst induces him to indulge, and thus one source of deception is
created.
In less than 24 hours from the supervention of the symptoms just
described, the patient's fate is decided. Sometimes suppuration
soon sets in, and the slough of areolar tissue escapes with the pus,
or through the medium of an abscess formed in some part of the
limb; all then goes on satisfactorily. Usually, however, this happy
change docs not occur ; the wound opens out more, the lips become
further everted, a bluish line is perceptible where the vesication had
existed, and the fetid serous discharge increases, in some instances,
816 1>i: \Vii.\ioi
inch an amount as to saturate the band ad the bed. A-
these changes proceed the patient complaint of leaf pain, until at
Length it i- altogether abaent. The moat etriking local feature now,
I one which makes the - rotrast with the form of gangrene
last described, is tlie total absence of any doughy tumefaction;
indeed, from tirst to last, there is neither ten-ion nor swelling of any
kind, save some puffiness around the wound, and even crepitation,
which can only be elicited by very firm pressure, is not alws
present. No Bloughing of the skin, beyond, at least, the margins
of the wound, or what may be the result of the previous mechanical
\ iolence, is ever observed in uncomplicated oases of this kind of
gangrene. The appearance of the wound and fetid serous discharge
at first, and later the constitutional symptoms, are the only means
whereby we can recognise sloughing of the deep areolar tissue, and
the consequent blood-poisoning.
At the time that the wound, by the fuller development of those
characters first observed, gives unequivocal proof that all hope of
suppuration occurring is at an end, and the gangrene is spreading,
the constitutional symptoms undergo a serious change, and evidence
is quickly afforded that the blood has become poisoned to a fatal
extent. The pulse, before soft and full, and not exceeding i)0 beats
in the minute, becomes quick and weak; the vomiting is incessant,
being accompanied by hiccup, or, what is worse, a sort of gulping
effort; there are insatiable thirst, a dry brown tongue, and a
tympanitic state of the abdomen. The yellowness of the skin gains
a deeper tint, the features are contracted, and there is a peculiar
sunken expression of countenance; the point of the nose, the lips,
and one or more other spots on the face, especially over each malar
bone, present a congested appearance, and this, mingled with the
general yellowness, gives that remarkable leaden hue which was so
much looked to by the older surgeons, being considered by them as
characteristic of gangrene. As time goes on the fatal symptoms
advance. The pulse becomes irregular or intermittent, the patient
falls into a cold clammy sweat, he complains of a sense of constric-
tion across the precordium, which is sometimes most distressing;
there are jactitation and muttering delirium. Yet when roused he
will, in general, answer questions rationally, and is often able to
raise himself in bed and take some drink, thus evincing a degree
of strength, which inspires false hopes in those incapable of drawing
conclusions from the local and general condition of the case. Soon,
however, coma comes on, and in a couple of hours closes the scene,
Db. WUMOT <m Acute Gangrene. 317
not more than -><> hours having, as ;i general rule, elapsed from the
first announcement, given by tin* wound, that gangrene of'the areolar
tissue around the broken fragments had commenced.
The most characteristic local feature, aparl from the aspeel of'the
wound, is the absence of swelling, the limb being, to the last, rather
soft and flaccid than otherwise, and those of a general character are
the incessant vomiting, the yellowness, and later, the leaden shade
of the skin of the face, and the abruptness of the supervention of
fatal symptoms. In the diffused gangrene death supervenes rapidly,
hut the transitional steps are comparatively gradual; in the form of
gangrene, however, now alluded to, the succession of fatal symptoms,
once the blood becomes fully poisoned, is so sudden and abrupt as
to take all parties by surprise.
With respect to amputation in this form of gangrene, the question
is to be viewed in a particular light. In the diffused gangrene we
saw that so long as the vital powers did not sink below a certain
point, and the knife could be carried through structures not actually
in the process of dying, amputation was a proper measure, and
afforded some grounds for expecting a successful result ; but in the
case of gangrene of the deep areolar tissue, the operation is worse
than useless, unless as a measure of anticipation, for it is obvious that
once the general symptoms give evidence of thorough poisoning of
the blood, removal of the source of the mischief comes too late.
Yet, to operate before all chance of suppuration being established
and the gangrene arrested has passed, would be most unjustifiable:
hence closer watching and greater preparedness are called for.
After the wound has made the first declaration that sloughing has
commenced, however feebly the signs may be manifested — however
slight the change — the greatest vigilance is demanded from the
surgeon ; and if, in a short time, the local features should be more
strongly marked, and the pulse become quicker and weaker, and the
irritability of stomach continue, we should, without delay, resort to
the operation. By temporising we only give time for the morbid
poison to be absorbed, and to produce its deadly effect upon the
brain and other vital organs. Still, even though the operation be
performed at the most appropriate moment, the chance of success it
offers is so indifferent as to make it imprudent for the surgeon to
urge it too strongly upon the patient or his friends, should he or
they exhibit much hesitation in yielding consent.
The inquiry that now arises La this: — Are there any means which
the surgeon can adopt calculated to avert or to diminish the risk of
1 >l; \\ ii.Moi .1
either of these form j 1 believe a m
sntial p. »iiit \- to reduce the b<> dilj m possible, mak
the ends smooth and even, and coapting them perfectly In all
where the bone protrudes, whether from direct or indin
\i Aenoe, the end i- always d and irregular; and it if obvious
that the effort to effect reduction, and the injury done to the areolar
tissue by the rough spicula after the bom-.- are returned, must greatly
increase the chance of gangrene of that tissue ensuing: hence it
jary to saw off some portion of the broken
fragments, either with the view of facilitating reduction, or of
rendering the extremities smooth and even, or of effecting both
purpos
The quantity of hone to he removed depends on the extent of
the protrusion and the spiculation of the ends. We should have
them smooth and fairly eoapted, no matter how much it may be
necessary to saw off; far better is it to allow the limb to be per-
manently two inches short than to expose the patient to the remote
chance of sansrene of the areolar tissue. Nothing can be more
unsurgical, and more likely to lead to all the evils consequent on
compound fracture, than making violent traction to accomplish
reduction of the bones, when the removal of a small piece of the
bone, by means of a saw, would enable the fragments to fall into
easy and perfect apposition. The best sort of saw to employ is a
small one, on the principle of Mr. Butcher's, the serrated edge
being turned upwards, so as to saw the bones from below upward-;
thus the soft parts are defended without any of the stretching, and
the trouble consequent on the use of clumsy retractors. As the
lower fragment seldom protrudes, and is overlapped by the upper,
it is often difficult to get at it satisfactorily, so as to take off a
sufficient portion of bone; but in general, by means of the saw
alluded to, and a good cutting forceps, all spicula and roughness
can be removed.
The bones being rendered smooth, and properly eoapted, the
limb must be left as tranquil as possible, and the disturbing action
of the muscles must be controlled by mechanical means and
by anodynes. There has always been much difference of opinion
as to the best mode of placing the limb ; but this consideration
depends altogether on the exact situation of the fracture, and its
direction. If the fracture be in the lower third of the bones, and
be oblique from above and without downwards and inwards —
aming that the ends have not been removed, or not to a sufficient
Dr. Wil.moi mi Acute (iaiKjrene. 319
extent to render them transverse -tin- old plan of laying the Limb
on the outside, with the knee Hexed, fa the beet, often the only,
means whereby the hours can he kept in imposition. Ihit should
the line of the obliquity be from above ami behind downwards and
forwards, the limb must real on the back; and for this purpose the
Bwinging apparatus is most desirable. The latter La the position
which, in all cases, musl eventually he assumed; for, should the
limb be left long <>n the outside, with the knee flexed, not only is
there much pain to the patient, and trouble and difficulty to the
Burgeon in straightening the joint, but the suppuration which so
frequently occurs in the sheath of the muscles on the outside of the
leg is apt to escape notice until a Large abscess has burst either
above the outer malleolus or below the head of the fibula. The
position of the limb opposes the escape of the pus from the wound,
it therefore gravitates to the bottom, leading to a lodgment there,
thus favouring the formation of the large abscess alluded to. A
fortnight is long enough to leave the limb in the flexed position ;
at the end of that time muscular action and the mobility of the
bones will be lessened so as to admit of the fragments lying in
tolerably good apposition when the limb is placed on the back.
Seeing that both forms of gangrene are purely constitutional, it
follows that, as a matter of primary importance, strict regard should
be paid to every circumstance contributing to the general health.
If the patient's residence be in vitiated air, he should be removed
therefrom, as soon as possible, after the accident; and, under any
circumstances, his room should be well ventilated, free admission
of pure air being secured Of all influences exercising a depressing
effect on the system, and thereby predisposing to gangrene and low
fonns of inflammation, none is more powerfnl than impure air.
Many persons will apparently enjoy good health in abodes where
the air is not only stagnant but impregnated with foul gases ; but
when such become the subjects of injury, especially of wounds and
cuts, then the evil is to be witnessed either in the supervention of
erysipelas or of gangrene, or in the utter failure of reparative action.
How often do we find the one result averted and the other corrected
by changing the individual into pure air.
Next in necessity to free circulation of pure air in lessening the
predisposition to gangrene is the supporting the patient's strength,
from the starting point, by nutriment, wine, and tonics. In in-
juries of all kind- the practitioner is apt to withhold these measures
until actual debility demands them; but in every instance where
1>k 1. on
forms of inflammation are to be app I «1 ire
must, from tin- commencement, <l>:il liberally with th<
especially prds wine. Of medicines, the sulphate of quini
i-^ unquestionably tin- beet.
Alii'. XIV. — Commentaries on Diseases of the ILut awl I
By Robbbt D. Lyons
Tin: following observations will, I trust, be received with indulgent
consideration. Their object is to discuss, doI in Bet manner or in
systematic order, some points which appear to me of practical
interest and importance in the pathology, diagnosis, and treatment
of certain forms of disease of the heart and great vessels.
Irregular and Intermittent Heart and Pulse, without Discoverable
Organic Disease. — The phenomenon here indicated I have had
occasion to observe in youth, in adult, and in old age, in connexion
with acute as well as with chronic disease, and also in conditions of
the system in which no other lesion was present.
1 have observed the following amongst other instances of irregular
cardiac and vascular action: —
1. .V Btate pretty common in persons of <>0 years of age, and
upwards, in which there IS momentary arrest of the cardiac and
radial beat once, perhaps, in a minute, and this at certain intervals
in the day, and not observable at all times. During confinement to
bed, from trivial and temporary ailments, especially those affecting
the chest, this phenomenon becomes more constant. It often then
recurs twice or three times in the minute, and is followed by a
peculiar hurried action of the ventricles for three, four, or half a
dozen beats. The momentary cessation of the cardiac action is in
some patients sensible to themselves, is attended by a thrill of
apprehension through the whole system, and is often the cause of
much anxiety and distress of mind. I have, in some well marked
cases of this affection, observed the presence of very fully developed
areas senilis around the cornea. So far I think this supports the
assumption that the irregular cardiac action in question is due to
a weakened, flabby, and probably fatty condition of the ventricles.
It may be further noticed, that in cases of this kind the heart's
action is very much influenced by the respiratory movements Thus
DlBeQMBOftKe Heart >nnl \'cssids. 321
■ sudden oough, or an unusually < l* m * j » inspiration, or any sudden
oheck to either the inspiratory or expiratory efforl will be sufficient
to cause an immediate, but momentary, arresl of the heart's heat and
the radial pulse.
The practical therapeutic indications which I think derivable
from the consideration of these phenomena are to avoid lowering
and depleting measures when such patients arc affected with subacute
bronchial, or other pulmonic lesions; and, on the other hand to
fortify the system, and the heart especially, by nourishing broths
and a liberal but judicious use of stimulants.
i>. A state in which, in persons of adult age — 30 to 40 — irregular
action of the heart, with momentary cessation of its beat, occurs i\
the condition of physical and nervous prostration which supervenes,
to that of inordinate excitement maintained for ten days or a fort-
night at a time by excessive indulgence in alcoholic drinks. One
of the most marked instances of this kind which I have met with
was recently under my observation. There was great sense of
depression, collapse, and weakness referred to the cardiac region,
the patient putting his hand upon the heart, and saying, " It is all
there." The cardiac impulse was found to be feeble, the rate of
circulation from 65 to 70, and the first sound weak. A cardiac
pause occurred at about 15 to 20 beats for two or three days; it
then became more irregular, and occurred once or twice in every
two or three minutes ; subsequently it occurred only during part of
the day, towards evening, when the patient's system ran down;
gradually this symptom disappeared. The same patient, on several
previous occasions, after excessive abuse of alcoholic drinks, com-
plained of great cardiac sinking and depression ; but the heart and
pulse never before exhibited the phenomenon of momentary inter-
ruption of its beat.
I have, in several instances, noticed the connexion of dipsomaniac
indulgence with great languor and debility during portions of the day
— usually the afternoon — coupled with cardiac depression and feel-
ings of a hypochondriacal character, and with melancholy forebodings.
The circulation is, under these circumstances, found to be languid,
the heart's action feeble, the sounds dull, and wanting " tone" and
"ring;" and the pulse at the wrists is readily compressible, and
wanting in resiliency.
I feel persuaded that this train of symptoms is connected with
incipient fatty degeneration of the muscular structure of the heart.
Bracing air, tonics, the \ (reparations of iron, animal food at frequent
VOL. XXXIII., NO. 6Q, N. S. E
1 )l I .
im and moderate simulation, iallj bj luoh m
those of the Burgundy vinl which fortify and invigorate with*
out producin itement of the circulation— are tin Liee
which 1 have found meal beneficial l h meant I hare no
>t that cardiac degeneration can be arrested
Another, and more singular, form of cardiac irregularil
that which I have found to occur in persons of advanced age. The
pulse Lb slow — at or under 40 in the minute; it ia a long, slow, and
labouring pulse-wave, which Lingers under the finger, hut is altogether
devoid of resistance or force, and can be completely extinguish
by Blight pressure. The cardiac impulse is extremely feeble; but it
;- on applying the stethoscope that the most marked phenomena are
discovered. The rhythm of the cardiac sounds is altered; and, in-
ad of a double sound, we mav find a treble or quadruple Bound.
One very well pronounced example of this affection came recently
under my notice. The patient was aged over 70 years, a female.
The pulse at the wrist was hardly 40, and this seemed its perma-
nent rate. The cardiac impulse was very feeble; and, on applying
the stethoscope, a distinctly triple rhythm of the heart's sounds was
audible. This, be it observed, was not a temporary or momentary
condition, but one which we found, after repeated examination, to
be, so to speak, the normal state of the heart's action in the patient.
I conclude this case to lie another example of weakened and
probably fatty heart. The occurrence of treble, and even quadruple,
sounds attending the heart's beat I think admits of ready explanation
by a want of synchronism in the action of the Beveral pairs of the
parts of the heart which, we know, usually perform their motions
together. Thus, if the ventricles do not contract at precisely the
same moment we have doubling of the first sound ; if the great
vessels, aorta and pulmonary artery, do not react on their contents
at precisely the same instant, reduplication of the second sound
will be the result.
We know that, under the influence of nervous excitement, in
young females, in certain chlorotic states, and even in males at or
about the age of puberty, and under other conditions not well
defined, a triple rhythm of the heart's action is occasionally induced.
It is in these instances, however, but a transient and temporary
phenomenon, and disappears under treatment.
Feeble Heart, with Hypochondriacal Symptoms. — Another class
of cases may be now noticed. They occur, so far as my observations
Dieeaeee of the Heart and Vessels.
extend, chiefly in individuals of rather full and plethoric habit, and
who are BUpposed to be iu robust health. They are usually persons
iii the prime of adult life, 80 to 1") years of age, rather over than
under the middle height, well coloured, of energetic minds, and at
one period of their lives, if not actually BO when under observation,
of vigorous frame, and capable of undergoing much physical exer-
tion. The appetite is usually good, and the various functions of the
body are performed with regularity. What, it may be asked, are
or can be the ailments of persons apparently in such rude health?
When individuals, in the circumstances now under consideration,
make known their complaints it is not unusual to find them treated
by their friends as "fanciful," " hippish," or "indolent;" and so
much do appearances belie their statements that they are not always
accorded sympathy, still more rarely entire credence. And yet
their ailments, and I may even say their sufferings, are as real, and
occasionally as severe as those which occur in disease of a less
questionable character.
In these cases it will often be found that the patient complains
much'of general debility, with total prostration of nervous energy, and
sensations of great weakness, sinking, and even collapse — the latter
chiefly referred to the cardiac region. There is much hypochondriac
feeling, with morbid forebodings, and an irresistible melancholy
seizes upon the mind, which it is found impossible to shake off by
any effort of the will. In some patients these symptoms prevail
during a great part of the day, and constitute an aggregation of misery
and distress that eventually becomes almost intolerable. In other
instances it is only in the latter half of the day that the patient's system
runs down, as it were; or, as it was on one occasion very strikingly
illustrated to me, the patient feels as if the system were like a piece
of clock-work, wound up and set to go for a certain number of
hours, during which nervous and mental energy were well sustained,
and physical exertion, even of considerable amount, could be well
borne. A moment seemed to arrive, however — in this instance
al tout one o'clock in the day — " when the weights had run down," the
clock-work ceased to go with its previous energy, and the patient,
feeling the nervous system all unstrung, and the muscular apparatus
feeble and relaxed, was no longer capable of voluntary exertion of
the will or mind to the full extent of their powers. Feelings of
melancholy, depression of spirits, sighing respiration, disposition to
lie down, and, in some instances, a heavy sleepy state supervene.
In some cases recourse is secretly had to the use of stimulants, from
e 2
Db 1 . \menku
the knowl< -vhich the patient* haw, by experience, Acquired
their efficiency in, at all eventi temporarily, relieving the state of
mretohedness ami depression into which they are Accustomed to
-ink at a particular hour of the da\
The heart's action and pulse are usually, in tin
feeble, the radial pulse being " shabby " and •• thready." 1 h* ra if
manifestly an incomplete and inefficient circulation of blood, due, 1
think, primarily to a weakened and atonic, state of the ventrici'
and possibly, at a subsequent period, to incipient fatty degeneration
Change of air, horse and foot exerci-r in a bracing climate, atonic
regimen, frequent use of broiled meats, an early and light dinn-
avoidance of succulent vegetables, the moderate use of brandy rather
than whiskey, properly diluted, and the more tonic and invigorating
wines of the Burgundy rather than the claret vintages, I have found
to be attended with most excellent results. In many of the
es there is a mechanical as well as a physical connexion and
dependence manifested between the stomach and heart. The state of
collapse above described is generally found to occur about the time
that the stomach is empty and idle. A small quantity of broiled
meat, with a glass of Macon, Beaune, Volnay, or other tonic Burgundy
wine at this period of the day will be found an excellent stimulant
to the heart as well as to the whole system. The bitter vegetable
infusions, with or without the preparations of iron, are also indicated ;
while in many cases the ammoniated tincture or the infusion of
valerian, given in effervescence three or four times a day, will be
found highly beneficial.
These cases, if neglected, have unquestionably a tendency to run
on into confirmed fatty degeneration of the heart — a full develop-
ment of which state may be anticipated between the 50th and 60th
years, if not earlier.
Aortic Murmurs. — In young and otherwise healthy persons, males,
at or about the age of puberty, I have in several instances observed
murmurs referrible to the ascending portion of the aorta, and in
point of time following, with a slight but appreciable interval, on
the ventricular systole. The individuals in question appeared in
the enjoyment of fair average health, being well nourished, well
coloured, and in no respect anemic or chlorotic, and of vigorous, if
not robust frame. In some instances the murmur was detected in
consequence of an examination of the heart being asked for by
reason of slight palpitation and distress in the precordial region.
Diseases of ike Hurt and Vessels. 325
In other instances I have become aware of the presence of this
variety ofmurmur, under circumstances which called for a genera]
exploration of the chest, bul in which no suspicion was entertained
by the patient himself thai anything abnormal existed in the action
of the hear! <>r vessels. The murmur lias been usually of a some-
what rough blowing character. 1 have found it limited by the
aortic valves, and in no instance diffused in the direction of the
ventricles. I have more than once known it to be scarcely audible
till the stethoscope was passed an inch or more above the level of
the sigmoid valves. Its point of maximum intensity was about the
junction of the middle and upper third of the sternum ; and, though
audible at the top of this bone, it was but faintly propagated into
the carotids. The ascending portion of the arch of the aorta and
its contained blood must be interrogated for the cause of this
murmur. The integrity of the valves of the aorta seems to me to
be guaranteed in these cases by the faintness, and, in some instances,
absence of the abnormal sound at the " cardiac centre," and the
purity and clearness of the second sound in this situation in all the
cases that I have observed. Spanemic and chlorotic states of the
blood I have judged not to exist, from the well-nourished condition
of the body, and the florid colour of the face and surface generally.
In persons of more advanced age atheromatous states of the aortic
walls, with or without calcareous degeneration of the inner coat,
and the production of the so-called " osseous" plates will readily
account for murmur localised in the aorta, and unattended by
abnormal valvular sound. It is well known to pathologists that
even in very advanced states of degeneration of the walls of the
aorta, extending to within a very short distance of the origin of the
vessel, the semilunar valves will often be found in a condition of
perfect integrity, retaining their transparency, and being in every
respect adequate to perform the office of closing the mouth of the
aorta, and preventing the return of the blood into the ventricle.
But though atheromatous change is possible, it is certainly of
great rarity prior to, at, or shortly subsequent to puberty. I think
we may even assert, in general terms, that atheromatous disease is
of exceptional occurrence prior to the thirtieth year of life. (I have,
however, myself seen well marked exceptions to this rule.)
It becomes a question of great nicety, as avcII as of much practical
importance in reference to prognosis, to determine the nature and
source ofmurmur in the class of cases in question. If of organic
origin, and dependent on atheromatous degeneration of the aortic
1 )•
Us, are can at best but anticipate slow aneuriama] dilatation of
the primary arterial trunk, with the probable formation of a fusiform
11 trui-" aneuriama] tumour in the cheat l>y the tame the patient
ihea his fortieth or forty-fifth year. In the interval he run- the
risk of rupture of the more inelastic aikeromatUed inner, and middle
as of the aorta, as the result of any unusual Btrain the reesel
ma\ be subjected to by blows upon the chest, violent muscular
exertion, forced reapiratory efforts, or other agencies of similar efB
Rupture of the coats of the Teasel will, of course, be Bpeedily fol-
lowed by the formation of "dissecting*1 or "false*' aneurism, a
diseased state which, under the most favourable aspect, is incom-
patible with a protracted duration of life — for Leas so, as will be
subsequently shown, than in cases of "true*' aneurism.
To put the problem in question in a definite and concrete shape
before us we shall pose it thus : —
Given — A youth, from 17 to 25 years of age, well formed, of
medium stature, build, and weight, well nourished frame, and well
coloured complexion, with every evidence of well arterialised blood,
and all the functions discharged in a healthy manner, the circulation
being tranquil, or but slightly disturbed. It is desired for any of
the reasons, half social half commercial, so numerous in the present
day — to insure his life for a liberal sum. The most careful general
exploration gives no e\ idence of disease, with the exception of a
rough, blowing murmur audible in the aorta, not heard at the
cardiac centre, but more or less audible in the carotids. Whether
i- the examining physician to recommend for insurance or to reject
such a life?
It is unnecessary to dwell on the important issues at stake, and
the responsibility that attaches to the verdict of the medical prac-
titioner under these circumstances. And be it remembered that
they are circumstances in which compromise of opinion is impossible.
He has but one alternative — to reject or to recommend the life.
Now I believe that, guided by precedent, and by what may be
deduced from systematic works, the life in question would be
rejected in the majority of instances. And yet I am persuaded the
decision would be an incorrect one.
Besides others that have come before me at various periods, I
have more recently had the opportunity of observing not less than
five cases of this affection. The murmur is well marked in all ; in
all the limits of its diffusion are those above assigned ; and in all
the frame is well nourished, and the blood well oxygenated ; in two
f)is,;tsrs <>/ thf Heart and Vessels. 827
there is, <>r rather wes, for a time, sligh1 palpitation and some Blight
cardiac uneasiness ; but in none of them is there the slightest
abnormal sound, or action to the heart itself. In some instance- I
have known the murmur to disappear altogether in the progress of
the case.
In tin' five examples now cited the murmur remains, and there-
fore they inav be considered still subjudice. I have myself, how-
ever, acquired the strongest conviction that in no single instance
out of the five Lb the murmur dependent on atheromatous or other
organic change in the walls of the aorta. This conviction I base
on the following considerations: —
(a). The youth of the patients.
(6). The absence of pain, distress, or uneasiness, referrible to the
aorta in the majority of cases.
(c). The tranquil state of the circulation.
(d). That I have known the murmur to disappear in similar
instances previously observed, the action and sounds of the heart
and aorta being perfectly normal.
Obstructive Disease of the Aortic Orifice. — In this important form
of lesion of the heart the usual phenomena are those of impeded
circulation, systolic murmur propagated into the aorta, cardiac
distress and palpitation, and finally death, from the effects of im-
perfect circulation, venous congestion, secondary engorgement or
the lungs, liver, and kidneys, and dropsy in the extremities or the
great cavities. It cannot however, I think, have escaped the notice
of observant physicians that cases agreeing in the acoustic pheno-
mena, and therefore, and justly so, classed alike as instances of
aortic obstruction, differ very widely in duration, in the amount of
suffering entailed, and in the general state of the patient's health
and fitness or capacity for the ordinary avocations of life. In some
of these cases a fatal issue ensues after no long interval, and with
much suffering ; in others, as in the following instances, a compa-
rative state of health and physical comfort is long maintained.
One of our dispensary cases at Jervis-street Hospital exemplifies
in so striking a manner the principles involved in our first and
second propositions, that I think it will be useful to consider its
features somewhat in detail. Several of our pupils recently exa-
mined the case of Mrs. M.. amongst our out patients, at that
institution. She is a healthy -looking, fresh-coloured woman of
middle stature, comfortably clad, the wife of an artisan, in moder-
Di Lyons l omrntntarm on
circumstances for hia position in Life It i- worth}
remark, thai this woman Bought advice for a triflii ement
of the itomaoh, with foul tongue, and of recent origin. She made
do complaint or reference whatever to her heart till the perceived,
after she had explained her gastric symptoms, thai I * i I * i n«>t identify
her. I had, however, recognised her face as one perfectly familiar
to me. She then mentioned her name, and the met of her bavin
been under my care for " Heart Disease'1 tv. 3 and a half pre-
viously. This brought her case, with its history, Bymptoms, and
pathology to my mind in all its vividness. Fresh inquiry elicited
a repetition of her history, to the effect that some seven years since
she had an attaek of rheumatic fever, subsequent to which she
complained of heart affection. At the period of my last seeing her,
two and a half years Bince, she went to the country for change of
air, l>v my advice, and she has since not only enjoyed very fair
health, but has borne another child, now just weaned. She is
perfectly aware that Bhe has "the Disease of the heart,'1 as they
generally term all cardiac affections. She sutler- but very slightly,
and that only occasionally.
Now let us see what are the stethoscopic signs in this case. I
examined her with much care and interest, and many of the pupils
can confirm the observations then made. The pulse at the wrist
was regular, and in no way remarkable for excess or deficiency of
force or volume. The cardiac impulse is full and sensible over an
increased surface of moderate extent ; the precordial dulness is
likewise increased in extent to a moderate degree. On applying
the stethoscope a very loud whirring murmur is audible with the
first sound of the heart, or rather replacing or drowning it. This
murmur i< very intense, much louder than in any of the other
cases at present under observation. It is audible from the apex to
the base of the heart ; it is propagated up the line of the aorta, and
is heard at the root of the neck and in the carotid arteries with
great intensity; it can be traced as a very loud sound, and still of
a whirring character, in the descending thoracic aorta ; it is audible
between the scapula? and over the last dorsal vertebra); it is heard,
almost with the same intensity, in the lumbar region; and it is
perfectly audible and distinct when the stethoscope is carried to the
lower end of the sacrum. And it is to be borne in mind, that in
this case our examination was made through the numerous and thick
folds of a female's dress. I have no doubt that the murmur is
audible in this patient in the iliac and the femoral arteries, and
Diseases of the Heart and Vessels. 329
perhaps through the whole arterial tree. Now, note again the
remarkable features of this interesting and instructive case. The
patienl makes no complaint of head symptoms; she has for two
yean and a half enjoyed average health, with freedom from cardiac
distress, except at rare intervals, and she then suffered but little.
There is little, if any, disturbance of the equilibrium of the circula-
tion. Not only have the functions generally been performed with
every indication of integrity on the part of the great organs, but she
has safely gone through that most wonderful of God's operations
performed in the human economy, viz., that of child-bearing, and
the subsequent process of suckling her child.
Taking it all in all, there will rarely be met with a case more full
of interest and instruction.
From the fullest consideration which I have been able to give
this case I regard it as an instance of obstructive disease at the
mouth of the aorta, the result of vegetative growth in the semilunar
valves, which offers a certain amount of impediment to the egress
of the blood from the ventricle into the aorta, by which it is thrown
into vibrations, and so the murmur is produced synchronously with
the first sound of the heart. But observe, the second sound of the
heart is, in this case, perfectly pure, clear, and distinct. From this
we infer that the lesion of the valves is such that while it impedes
the outflow of the blood from the ventricles, it in no way interferes
with the integrity of the aortic valves, and they are, therefore, as
fully able as in the state of health to close the aortic orifice, and so
prevent regurgitation from the aorta into the ventricle.
But we have, I think, in this case something special in the cardiac
mechanism, under its new conditions of disease.
I may compare for a moment the case of Mrs. M. with that of
poor G., another patient in hospital, with similar stethoscopic signs
of disease. In the latter instance we have great cardiac suffering,
the equilibrium of the circulation is profoundly impaired, the lungs
and liver suffer in consequence, there is much oedema, general
debility, and incapacity for exercise, not to say manual labour or
active avocation of any kind. And yet the case of G. presents
essentially the same stethoscopic phenomena. There is but a single
murmur; it is systolic or audible with the first cardiac sound; it is
propagated up the aorta. It is not, to be sure, of anything like the
same intensity a< that in Mrs. M. ; it is not propagated one-tenth of
the distance; it has not the same whirring character. But all this,
if we confined our attention to local and stethoscopic signs, would
Db Lyons i
only mislead us, for we should be led u, imagine that Mi- M'i
w i- in the wora of the two. \\ I in practical realit
M: M j state of health la one of oomparativ< Q Ii
one of much Buffering, and our prognosis must be of the moat
unfavourable kind, and implies a speedy issue in death. Th
both cases of non-regurgitant obstructive disease of the aortic rahr<
Wherein do fchej entially differ? Are ire to assume that it
i- a mere Break of disease; that hi one there is tolerable health over
a period of at least two years and a halt", and this compatible with
child-bearing and nursing; while in tin- other the debility i- extreme
and the Buffering erreat? It is not a freak of nature or disease:
this is, 1 believe, a term of a by-gone day, and implies insufficiently
or unsuccessfully explored oaua
From a review of the numerous morbid specimens which an- in
my possession 1 think I can satisfy myself that there exist two very
distinct forms of non-regurgitant obstructive disease at the mouth
of the aorta. (The various proofs from examination and com-
parison of specimens cannot be given in print in the absence of
illustrations.) In one of these forms it maybe observed that the
aorta is constricted at its mouth, and the vegetations are BO placed
as to present a very serious obstacle and impediment to the egress
of the blood from the ventricle. L shall call this variety obstructive
aortic valve disease, with narrowing of the mouth of the aorta — for
brevity sake we shall term it " obstructive Btenosis." It is well
exemplified in some of my specimens; it is what I believe exists in
the case of G. It is necessarily attended with great disturbance of
the equilibrium of the circulation, and a permanently incomplete
and ineffective circulation of blood. The lungs, the liver, and the
other organs so directly implicated when the balance of the circu-
lation is destroyed in the heart's chambers, become necessarily
diseased in this form of valvular lesion.
Now, contrasting other specimens, I find there exists obstructive
disease, it is true, in the aortic valves; but though the vegetative
masses are considerable, the mouth of the aorta is larger than
natural, and though the warty vegetations obstruct the blood as it
flows from the ventricle, still the vessel is so capacious that no
serious impediment to the egress of the blood takes place. The
impediment is sufficient to throw the blood into vibrations, which
cause systolic murmur, but the circulation is efficiently maintained,
for the great arterial tube readily admits of the free passage of the
blood through it. This latter condition I assume to exist in the
D/srasrs of the Heart and I 331
case of Mrs. M. I think we may, with propriety, designate it
obstructive disease al the mouth of the aorta, with a patulous, orit
mav be a dilated state of the vessel. We may, for brevity sake,
designate it "obstructive patency." There Lb one difference in the
signs in these two case-, to which I have not yet called attention,
and I presume it will hold for the two classes of cases. It is the
condition of the radial pulse. In the one class of cases, that of
Stenosis, it is a small weak pulse, that of an imperfect circulation.
In the Other class of cases, like that of Mrs. M., the pulse is natural
in force and volume; it is the pulse of a vessel receiving its full
charge of blood at each stroke of the heart. In fine, in the one case
we have a deficient and wholly inadequate circulation; in the other
the circulation is well and fully sustained, and quite as much blood
finds its way at each stroke of the ventricles into the aorta, and
thence into the peripheral vessels as in health, inalgre the vibrations
given to it at the mouth of the aorta, as it issues from the ventricles,
by the vegetations aforesaid.
I have elsewhere taken an opportunity of showing how the con-
siderations to be derived from a study of the states of patency and
stenosis apply to mitral as well as aortic valve disease. In my mind
they give us a new light to aid in the explanation of the apparent
anomalies and paradoxes which we have been accustomed to associate
with our ideas of cases, bearing the same technical designation, but
differing as widely in practical result to the patient as the cases of
Mrs. M. and poor G. are seen to do.
Another case, which bears out the foregoing observations, may
be cited from my note-book. It is that of a gentleman, then aged
36, whom I sawr in consultation about two years since. He was then
labouring under an aggregation of aggravated and apparently hope-
less maladies. At the period I speak of I found him suffering from
delirium tremens, extreme anasarcous swellings of the lower ex-
tremities, dropsy of the abdomen, and an anasarcous state of the
upper extremities and of the face. The urine was albuminous, but
not of low specific gravity. But his chief complaints were referred
to the precordial region and chest generally. The breathing was
hurried and oppressed ; much palpitation and cardiac distress being
complained of; the pulse was rapid and feeble; and on applying the
stethoscope over the heart a very loud, rough, and whirring systolic
murmur was audible, which could be traced up the aorta and into
the carotids with great intensity.
For more than a week this gentleman's life was despaired of.
Db. Lyons' <
Hia will \ touted in anticipation of an immediately I tie
treme delirious excitement prevailed to inch an extent that it a
.1 to impossible t»> keep him in bed, all those immediately in
attendance ob him being overborne l>\ tin- violence of hia den*
nour. The dropeioal state wbb daily increasing; and it was evident
that he was fast wearing out the slender thread of life that remained
to him.
Much against the will of his friends, who from former experience
supposed that almost unlimited supplies of stimulants were required
to maintain his system under the state of delirium, I insisted (and
not without much difficult) were my injunction- carried out) in
having- the supplies cut short. With the more rational frame of
mind thus soon induced we were enabled to enforce the regular nse
of diuretic and purgative medicines, and other suitable remedies
A rapid improvement in his state was speedily effected; a copious
drain by the kidneys and bowels was maintained for several days;
and ultimately we had the gratification to find that the dropsical
swellings completely subsided ; the circulating system became tran-
quilised; tliomjli the cardiac murmur was still persistent; the res-
piration returned to its normal rhythm ; strength was gradually
restored; and the patient was enabled, after the lapse of a couple of
months, to resume his ordinary avocations in the country. He even
acquired a very considerable amount of vigour, which he had been
:i Btranger to for a long time previous to his illness; -and, amongst
other things, it may be mentioned that, though married for some
five or six years prior to the illness in question, it was only about a
year subsequent to it that he became the father of a child. He still
lives in the enjoyment, I am given to understand, of fair average
health.
My interpretation of this case is very much the same as that given
for the preceding one, viz., that it was, or rather is, an instance of
" obstructive patency" at the mouth of the aorta. The dropsical
state 1 am disposed to refer to a temporary overturning of the
equilibrium of the circulation, with congestion of the lungs, liver,
and kidneys, induced by the state of excitement consequent on con-
tinued and excessive indulgence in alcoholic stimulants.
We can readily conceive, it appears to me, how in the case of
Mrs. M., and in that of this gentleman, the circulation can be fairly
maintained under the exigencies of the new conditions of obstruction
and patency at the aortic orifice as long as the blood is not driven
at too high a speed, or under too high pressure. The patency of
Diseases of (/i, Heart and Vessels. 333
the aortic orifice seems, under these circumstances, to compensate for
the obstacles opposed to the egress of the blood by the warty
vegetations on the valves. When, however, under alcoholic or other
stimulants t lie circulation is driven at a high pressure, the equili-
brium of the compensating agency and the obstruction becomes
lost; each cardiac beat IS attended with incomplete and inefficient
discharge of blood from the ventricle into the aorta; each successive
ventricular contraction and dilatation leaves a small surplus of blood
undischarged from the ventricular chamber; this of necessity tells,
in a retrograde manner, upon the left auricle and its blood-charge;
this again, in its turn, upon the pulmonary veins; congestive stasis
IS thus produced in the lungs; through the terminal radicles of the
pulmonary artery, through this vessel itself, and finally through the
right ventricle and auricle, and so through the vena? cavae to the
liver and other great organs and parts the impediment is propagated.
Finally, dropsy supervenes as a mechanical result of the congested
state of the venous system in the great viscera and in the extremities.
Pure Uncomplicated Myocarditis. — The last case I shall cite in
the present paper is one which I regard as of uncommon interest
and importance. It furnishes an example of complete restoration
of the heart to the most perfectly normal and regular action after
years of prolonged suffering from cardiac disease.
The patient, a gentleman now aged 44, of light but vigorous
frame, sanguine temperament, and active habits of mind and body,
and who had formerly enjoyed uninterrupted health, in the early
part of the year 1850 began to find himself in less satisfactory con-
dition than usual. In July of that year — and then suffering much
from debility and unpleasant sensation in the chest, with pain at the
left side — he consulted a physician, who pronounced him to be
labouring under " heart disease." The pulse was then ascertained
to be 120 per minute. Leeches, and subsequently blisters, with 20
drops of tincture of digitalis, three times a day, were the remedies
employed. Little or no improvement took place. And, speaking
of his own case in a very able report, which he has placed in my
hands, and which he has been good enough to review while in the
press — the patient says: — "I grew worse daily; the action of the
heart increased, with pain and soreness of the heart itself; until, at
the end of two months, I became unable to go down stairs, and was
obliged to sit on a sofa all day. and could not even move without
increasing the heart's action." The treatment was continued for
DB I • OIL
four months •• without further alteration;11 but it appears tin- pulse
vras reduced to 12 per minute In November, L850 Th
report continues: -•• I vras thru ina wretched, weak, nervous itate;
could not rest in the same position for a moment; nervous twitch-
ings, and horribly unpleasant Benaations all over the body.*1 About
the middle of January following, 1851, the h it into
excessive action. •• About the beginning of March I found
in a most wretched condition; heart's action ao rapid and violent;
the heating of the heart at night rendered sleep impossible; and
being deprived of the power of reading (from unpleasant sensations
in the head, caused by the effort to read, long complained of then
and subsequently), and unable to devise any other suitable occu-
pation or amusement, 1 thought I should go mad.'' Two or three
months subsequently some slight amelioration appears to have taken
place in the general state; but the head was not improved; the
patient " could not read three minutes consecutively without heat
and pain in the head, and horrible sensations extending from the
head downwards to the heart, and all over the bodj
Change of air and regimen subsequent to this produced some
considerable improvement in the general health and strength, 90
that the patient could walk some miles in the day (with repeated
intervals of rest ).
The history of this interesting case is protracted over the three
or four succeeding years, with many alternations of partial improve-
ment and retrocession. On the whole, however, a slow but gradual
amendment in the state of the general health, and in the condition
and action of the heart, took place between the years 1852 and
1855. Towards the middle of this latter year the patient found
himself well enough to resume his practice at the legal profession;
but he adds, " 1 cannot say that my health was perfectly restored
until 1857."
The various plans of treatment employed in this case comprised
digitalis, prussic acid, bitter infusions, ignatia, iron, zinc, and other
tonics. Vesication — or, as the patient himself terms it, "the
blister torture" — was continued every third day for ten months ; and
during four months longer the patient " was weaning himself off
it" — that is, continuing its use, but at longer and longer intervals.
A tonic regimen, with cold shower baths, was persevered in for
nine months with, apparently, some improvement to the general
health, as during its use he was able to walk about two miles in the
course of a day. But that there was no substantial gain may be
Diseases of ike Heart and Vessels. 335
judged from the fact which be states that M haying one day over-
fatigued myself, I was not able to stir (»iil for a month, and did not
recover the effects <>f it for the entire winter." Shortly subsequent
to this he underwent a course of hydropathic treatment, which was
prolonged for a year and a half. He appears to have improved a
good deal in general health for a time, while under this treatment,
which lie himself ascribes to " the effect of the air and regimen as
much, if not more, than the hydropathic treatment, which was
administered very sparingly at first." It is worth while to note,
that during this period his allowance of animal food was diminished
one half — his hydropathic physicians recommending little meat and
much vegetables. Hydropathy was abandoned in its turn; and
finally the patient placed himself under mesmeric treatment.
In proceeding to comment on this singular case I may premise,
that I had several opportunities of examining this patient at periods
when the heart was in a state of the highest excitement. Under
these circumstances the debility was extreme, the patient's sufferings
most intense, and the cardiac action almost more violent and tumul-
tuous than I have ever witnessed it in any other case. The face
was flushed, and the malar bones especially much congested, but of
a vivid, not a cyanotic hue. The pulse was rapid, 120 to 130, but
not irregular ; and it was not remarkable for force or volume. The
impulse of the heart to the hand, placed over the precordial region,
was very violent and tumultuous ; percussion gave no positive indi-
cations of much increased size of the organ ; but when the stetho-
scope was applied, a loud, diffuse, systolic bellows-murmur was audible,
with great and equable intensity over the whole precordial region.
No doubt remained on my mind, on any of the occasions on which
I examined him, that this gentleman laboured under incurable
organic valvular lesion, and that it was but a question of time as to
when the fatal issue might be expected. I believe I am justified in
saying that this opinion was fully shared in by all those who
examined the patient, and amongst them w^ere some of the ablest
stethoscopic observers whom I am acquainted with.
The subsequent history of the case is soon told. This gentleman
resumed the practice of his profession in the month of June of the
year 1 855, a- above stated. In the year 1857 he considered himself
perfectly restored to health. In the following year it became
desirable to effect an insurance upon his life, and from the entirely
satisfactory report of the examining physician as to the total absence
of all morbid signs or symptoms referrible to the heart, or indeed
1>k Lyons ( ommtntariti on
any other portion of the system, be w
On two subsequent occasions, it beoame my duti uninc hi-*
life for insurance, and after the most minute, prolon ful
bhoscopic examination of the heart, and a lull exploration of the
neral state of the Bystem, 1 could come to no other decision than
to recommend him, as a first-class life, to be insured without extra
ri-k premium. As in the; former instance, his life iras accepted in
both the Companiea for which I was concerned. It ia needless tu
add, that a full history of his previous illness was, in every cum-,
Bubmitted with the proposal for insurance, and the medical ex-
aminer's report. 1 may, in conclusion, state that while this pap
is in the press 1 have made a renewed and most careful exploration of
the heart in this gentleman. Its impulse and sounds are perfectly
normal and regular, and the pulse is equable, of moderate force and
volume, and steady at 72 per minute. In reflecting on this Nlly
singular, if not unique case, the following consideration- arise : —
1. It might be assumed that the patient laboured under a functional
affection of the heart.
2. The disease might be assumed to be of the nature of those
cases of chlorosis and anemia which we know may and do occur
in the male, but which are so much more common in the female.
3. It might be assumed that this gentleman laboured under an
obscure form of disease of the nervous system, with secondary and
symptomatic disturbance of the circulating system.
4. It might be supposed that the case was one of organic lesion,
affecting the mitral valves.
5. It might be assumed that the case was one of obstructive
disease at the mouth of the aorta.
Cor. — As a corollary to the 4th and 5th propositions, it might
be now assumed that the case was, or rather is, an example of
organic disease of either the mitral or aortic orifice, with sup-
pression of the murmur, usually attendant on those affections, in
the manner pointed out by myself and others.
6. It might be assumed that the case was one of pure, uncom-
plicated, but very chronic myocarditis.
That the last theory is the only tenable one, and that which will
alone explain all the phenomena of this very singular and instructive
case, I shall presently endeavour to show. We shall, in the first
instance, make a few observations for the purpose of refuting the
other theories which may, as we have seen, be advanced to account
for the principal features of this gentleman's case.
Diseases of the Hmrf <m<l Vessels. 337
Very singular and anomalous cases of functional disturbance of
the heart, musl be &miliar to all practitioners much versed in
cardiac pathology. I am not, however, aware <>f any instance, nor
indeed ran I even conceive die possibility of any such case, in
which functional disturbance of the heart was continued over such
i protracted period as in the example now before as. Besides, it is
beyond all question that the cardiac distress, pain, and tumultuous
action of the organ, with the quickened pulse, flushed face, and
vividly congested malar bones and general debility, observable in
this case, were positive and not subjective phenomena. The
violent ventricular impulse, and the loud whirring murmur audible
by the stethoscope, would have satisfied any observer that the case
■was one of organic lesion of some kind, and that no functional
derangement could produce phenomena of so unaccountable a
character. Against the hypothesis of chlorosis and anemia, the
patient's previous history, temperament (sanguine), habit of body,
and colour of surface generally, as well as of the face, consti-
tute, in my mind, conclusive evidence. Further, to judge upon the
good old rule, from the arguments furnished by the jiivantia and
lo?de?itia, iron and tonics failed to give the smallest relief, and so
far make directly against the supposition of any chlorotic state,
which, indeed, there was, in my mind, no ground for thinking to
exist.
In reference to the fourth and fifth propositions, it may be affirmed
that, in the whole range of cardiac pathology, we are not acquainted
with any facts that would warrant the conclusion that the valvular
apparatus of the heart, once impaired by organic lesion, can ever be
restored to perfect integrity. Indeed, the most superficial consider-
ation of the anatomical disposition and the delicate texture of the
semilunar or mitral valves, must satisfy us, from a priori reasoning,
that even slight injury of these extremely fine membranous expan-
sions does not admit of repair by any efforts of nature. While
pathological anatomy demonstrates that the various morbid conditions
of the heart's valves — such as fissure, cribriform perforation, ulcer-
ation, warty vegetation, calcareous deposit, or other change of what
kind soever — tend, in proportion to the duration of the case, to
become more and more aggravated morbid states. That, under
certain circumstances, in which the equilibrium of the circulation is
but little disturbed, life may be prolonged, in cases of valvular lesion
of the heart, for almost an indefinite period, we have already proved.
But we have no evidence whatever to show that organic change in
VOL. XXXIII., NO. 66, N. 6. F
Db. Li
the valves of the heart udmiti of radi return t.>
Is healthy action of t! m, and total all
: bid phenomer
It will be desirable to advert here to certain remarkable in
of temporary suppression of cardiac murmurs developed In connexion
with organic Lesion of the valves, and which, it
supposed would furni quate explanation of the
Qomena of the case now before as.
The temporary suppre >r even final cessation of murmur,
developed in the mitral orifice, 18 familiar to physicians fully I
in the pathology of the heart.
Such suppression of cardiac murmurs has been noticed in the brief
interval before death, when the heart's contractions Lose their accus-
tomed vigour, and the blood is not propelled with sufficient force over
the valvular irregularities to produce murmur.
Suppression of mitral murmur has likewise been noticed in certain
■s at a period long antecedent to death. It seems to be due to an
artificial re-establishment of the equilibrium of the circulation, and
■.lion of ventriculo-auricular regurgitation, by an adaptation of
the diseased, but now much thickened and enlarged valves, to the
mitral oritiec. These valves, which when first attacked by dise
were rendered incapable of closing the orifices which they were
destined to protect, become, by thickening of the valvular texture,
or by peculiar adaptation of the vegetative masses, again competent
to close the orifice, which in many instances has itself likewise become
adoptively diminished in size. I had myself an opportunity, some
years since, of calling the attention of the Pathological Society of
Dublin to a similar adaptive process, which I found to be effected,
in the case of the aortic valves, with concomitant suppression of the
murmur previously heard with great intensity.
Both in respect to the aortic and the mitral valves it is to be ob-
served, however, that suppression of murmur is not attended with
alteration in the general phenomena of the case. The disturbance
of the equilibrium of the circulation, and the consequent embarrass-
ment of the organs in physiological connexion with the heart remain
as before. There is no restoration to health, and the morbid condition
is sure to end fatally sooner or later.
In reference to the sixth proposition, it may be observed, in the
first place, that myocarditis, though comparatively unknown to the
clinical physician as yet, is a morbid state well recognised in the
records of pathological anatomy.
Di >f the Hear t and Vessels. 339
The oases cited by Testa, amongst other authorities, prove the
ooourrenoe of inflammation of the parietes of the bear! independently
of valvular Lesion; and abscess in the walls of the heart, though not
hitherto recognised during Life, is a well-known pathological occur-
rence. W re also know that several other Lesions of tlic miisenlar
texture of the heart present themselves in cases in which no lesion
of the pericardium, endocardium, or valves is discoverable. We may
cite, as examples, the softening of the heart in typhus fever, and fatty
degeneration of the heart. I have myself witnessed cancerous
deposit in the ventricular walls without any attendant morbid state
of the lining membrane, or the serous covering of the organ.
Inflammation of the muscular texture of the heart, irrespective of
valvular or pericardia] lesion, is thus, it may be concluded, a very
possible, I would even go the length of saying a very probable,
occurrence. Indeed, I am disposed to regard it as a morbid condition
of greater frequency than is commonly supposed.
It may be acute or chronic ; it may be attended with the formation
of abscess or purulent infiltration in a more diffuse form ; and, again,
we can readily conceive the occurrence of chronic inflammation of
the walls of the heart, without the formation of pus. Having, as I
think, conclusively shown that no other of the morbid states assumed
is capable of explaining the phenomena of the case of this gentle-
man, we are, I think, driven, par vote oV exclusion, to adopt the theory
of a pure uncomplicated myocarditis, to account for the otherwise
unexplained, and, indeed, unexplainable history of the case before us.
The general state of perfect health now enjoyed, after the lapse of
so many years, with the complete state of integrity of the circulating
apparatus, as tested by so many and so searching explorations, at
long intervals, by different observers, for the purposes of life insurances,
are conclusive proofs that no lesion impairing the valves existed at
any period.
The cardiac distress, pain, palpitation and murmur, diffuse and
not specially limited to any valvular area, and the occasional oedema
are readily explicable on the assumption of a chronic myocarditis ;
while the complete restoration of the heart to healthy action, after
years of suffering, is explicable on no other theory of cardiac patho-
logy with which we are yet acquainted.
f 2
Db Gobdo 6$.
\ x \ /.' ■ r. . Sami i.i. ( Gordon, m B.,
l'Mi C.S.I., Physician to tin- Biohmond, Whitworth, and Hard-
wicke Hospitals
( CoiUiuutd front Vol. xvii., p, 31 5. J
IV. Caw of extensive fatty degeneration in a boy 1 I
Death from obstructed arterial circulation. — A pale, unhealthy
looking boy, 14 of age, an inmate of a public school, came
under my observation on the 17th of October, oomplaini]
of severe headache, sore throat, and Loss of appetite. The throat
affection rapidly got well; he was confined to bed For only two
days, but not making a good recovery, he was retained in the
Infirmary. His symptoms seemed to be those of acute cardialgic
dyspepsia. He was pale and weak, and complained of weakness,
principally after his meals, when he also suffered from pain in
the stomach, and vertigo. He had constant headache, his tongue
was tumid, indented, broad and white, with enlarged papilla',
and his breath offensive; the bowels acted irregularly, and the
urine was pale and abundant. His appetite was very capri-
cious ; he was generally thirsty; he slept badly at night, but
was usually very drowsy through the day. His pidse was but
slightly quickened ; his feet and hands were generally cold ; and his
skiu was usually covered with a greasy perspiration. He had no
cough, and repeated careful stethoscopic examinations failed to
detect any physical sign of disease in his chest. Such were the
prominent symptoms under which he laboured, and from which he
appeared to be recovering but slowly, when, on the evening of the
5th of November, he was suddenly seized with acute pain in the
calf of the right leg. This pain was excessive, and kept him awake
all night. I found him the next morning still Buffering from it, he
could not bear the least pressure, nor, without great increase of
Buffering, allow any examination of the limb, which he kept in the
extended position, from which he could not alter it ; but, provided
that the calf of the leg was not touched, he could allow it to be
moved. The foot was cold and remarkably pallid, and from the
knee down was almost entirely devoid of sensation; he did not feel
severe pinching, and even pricking with a pin he felt but very
faintly. Thus, coincident with this severe pain in the leg, there
was paralysis of motion and of sensation, with remarkable diminution
of temperature. Careful examination failed to detect pulsation in
either anterior or posterior tibial arteries of the right leg, or in the
DB. GoimoN's Imports of liure Cases. 341
popliteal or even in the femoral, while io the opposite limb all these
arteries pulsated distinctly.
Nov. 7th. — The temperature of the righl foot hud fallen to 60°
at the toes, although the foot had been kept wrapped in warm
flannel, and frequently rubbed with b stimulating liniment. It had
sumed a cadaveric pallor and rigidity, but there was not the least
csdema nor venous turgescence nor capillary fulness; the anes-
thesia continued. The femoral artery could be felt like a quill,
rolling under the finger; and examination with the stethoscope (as
originally practised by Drs. Graves and Stokes, in a somewhat
similar case), proved that there was no pulsation in the right
external or common iliac or femoral arteries on the right side,
while it was increased in strength and rapidity in all these arteries
of the left side.
The case progressed slowly ; on the 9th, the foot appeared to be
regaining its natural heat ; the temperature had again risen to about
70°, and with the return of heat there was also a most marked
increase of power of motion and also of sensation. The patient
could now draw the affected limb up to him in the bed, and seemed
to prefer keeping the knee in a semiflexed position. He showed
more feeling in the foot and leg when they were handled, but the
pain was still very severe in the calf of the leg, and he shrieked
with pain when this part was touched. There were, on this day,
the following local signs of improvement: — 1. Complete freedom
from pain, as long as he lay undisturbed. 2. Increase of temper-
ature of the foot. 3. Return of sensation ; and 4, of power of
motion to the affected limb. But, on the other hand, the consti-
tutional symptoms all indicated extension of disease, the pulse had
risen to 120°, the respiration was hurried and unequal, and his
appetite began to fail ; moreover, the second, third, and fourth toes
began to be discoloured.
Nov. 10th. — There were added to the above symptoms, an
almost incessant short, teazing cough, without any expectoration.
Again the chest was carefully explored ; the heart's sounds were
very feeble but distinct ; the respiratory murmur was somewhat
rough and interrupted, but otherwise not abnormal.
The line of treament hitherto pursued, since the accession of the
acute attack, was the local application of anodyne and stimulating
embrocation- and liniment-, and the internal administration of bark
and bicarbonate of potash, with a full dose of calomel and opium at
night, and wine and beef tea at stated intervals.
Db G
11 Dr. Ilutton visited him with me: he I in
isidering tin- nature of the case to be an arterial affection, i
the local nee of mercury, and chlorate of potash ini
nally, which euggeetiona were carried out Be also surmised that,
although the case was clearly not a phlebitis, still it would m
probably be round to be connected with visceral dl
probably pulmonic ; and we again made accurate search for pi
as of pneumonia, or its allied diseases, but without effect
-Although the temperature of the loot has risen con-
siderably above what it was on the 7th, still it is considerably below
that of the opposite limb. The gangrenous action doc- not Beem to
be extending; it has reached a variable height in each toe, but no
where transgresses the Line of junction with the foot; it is nnaocom-
ied by vesication or osdema; he has no pain in any part of the
linih, except when pressure is made on the calf of the leg. He
complains to-day of a stitch in the left side, near the heart. A Blight
pitation i< heard in the lung at this part. A tew leeches relieved
him.
Nov. 17. — He coughs frequently, still without expectoration; his
face is pulled, and slightly (edematous; his lips blue; sonorous and
Bibilous rales, of variable intensity, are heard over all the ch«
Pulsation cannot yet be felt in any of the arteries of the right lower
extremity; still there is no oedema nor venous turgescenoe; the
temperature is still below that of the opposite limb; the power of
sensation and of motion in the extremity is almost natural. He
lingered until the 25th, when he died asphyxiated. The bronchitic
affection appeared to make rapid progress, resisting all treatment,
and the local affection remained most remarkably quiescent. Itwi
on one or two occasions, imagined that pulsation could be felt in
the tibial arteries ; but, at all events, it was not permanently restored ;
and to no other part of the arterial tree, from the common iliac
down, did it ever return. The limb retained its restored temper-
ature, which, however, never equalled, much less exceeded, that of
the opposite limb; and although the mortification had not passed
beyond the line of junction of the toes and foot, no line of separation
had formed. The heart was examined almost daily ; the impulse
was always feeble; the two sounds were always audible; and there
never existed any abnormal sound in the heart or large arteries.
Mr. Purser assisted me in making the post 7iwrtem examination.
The lungs presented a well-marked example of emphysema: when
the anterior Avail of the thorax was raised they did not collapse, but
Db. Gordon's Reports of Ran Cases. 343
presented b pale and bloodless appearance. They had the usual soft,
downy feel, and ;i section of them showed the widely dilated air
resides. The same Bection also showed thai ;i quantity of soft,
unhealthy, greyish matter had been deposited throughoul both
Lungs. This matter seemed closely adherent to the ?ery termina]
bronchia] tubes, which were excessively congested, and the Lower
Lobe of the lefl Lung was particularly engorged. The valvular
apparatus of the heaii was perfectly healthy. The right auricle and
ventricle contained a verj firm clot of fibrin, which also passed into
the pulmonary arteries, and into their Large branches, but did not by
any means till these vessels; otherwise; the contents of the cavities of
the heart were semi-coagulated, dark-coloured blood. The heart
itself answered most accurately to Paget's description of granular
degeneration. The post mortem examination was made in very cold
weather, about twenty-four hours after death; yet it was like a heart
beginning to decompose. The muscular substance was easily torn,
if with separation of fibres that only stick together, and the torn
surface was lobulated and granular like a piece of soft conglomerate
gland. The lining membrane of the aorta was very extensively
studded with small white spots, slightly raised above the surface.
The arterial system of the lower half of the body was very extensively
and minutely examined, and these appearances were found to exist
over a very considerable extent of the arteries, and were exactly
similar to the atheromatous patches, which Gulliver has proved to
consist of fatty matter, and which appear to be partly formed at the
expense of the middle coat, and partly deposited in a granular and
globular form under the inner lining. The canal of the aorta was
empty until we reached its bifurcation, when a solid mass of fibrin
found to block up the right common iliac artery. This clot was
found to ride over, or be fixed on, the actual bifurcation, a very small
conical piece of it projecting into the left common iliac artery. There
no further extension of it on the left side. This solid fibrinous
ma-s extended throughout the arteries of the right lower extremity,
hi >m< .geneous and continuous, from the commencement of the common
iliac artery until we reached to about the centre of the leg. Down
to tin- point the arteries had been completely closed by the fibrinous
mass, there being no possibility of any blood passing either through
ii or bj its side; and the lining membrane of the artery, and its other
coats, presented no appearance of disease beyond the degeneration
above mentioned, and that it wasofa red colour; but from the point
indicated, in both anterior and posterior tibial arteries, until we
3 11 DB ( s.
hed their most minute branches, the lining membnin
p red colour, and contained dark grumoui blood, which
long as the vessel was of any size, contained a long black coagulum
in the centre. The reins were healthy.
The spleen was swollen, soft, and contained numerous deposit
soft pultaceou8 exudation similar to those formed in the lun
Both the liver and kidneys presented well marked examples of
advanced stages of fatty degeneration.
The muscular structure throughout the body generally had, more
or less, lost its usual healthy appearance, and assumed a pale yellow
colour, was easily torn, and its substance was evidently loaded with
oil globules: but when we came to examine the muscles of the calf
of the right leg, where BO much pain was complained of during life,
we found them to be completely disorganized. The fleshy portions
of the soleus, with the llexors and peronei muscles, had lost altogether
their striated appearance, and were replaced by a Bui (stance not
unlike rotten sponge, which tore on the least force being used, was
of a dark grey colour, and seemed saturated with a thin oily fluid;
it had, moreover, the appearance of boiled meat, fly-blown, or in a
very early stage of decomposition, before any discoloration or fetor
have commenced; there was no appearance whatsoever of any
purulent infiltration. The entire body had a peculiar heavy odour,
such as I have often observed from cases of extensive fatty degene-
ration. There seemed to be a most unusual quantity of fluid blood
in the body, and that of a very dark colour.
There are several points of interest in this case. I would first
allude to the fact, that cases of arterial obstruction may be mistaken
for paralysis. It has been remarked by Grayes and Stokes, that :a
" In the advanced stages of this disease the diagnosis is not diffi-
cult ; there is paralysis, but this has not been preceded by symptoms
of central or spinal disease, and the intellects remain undisturbed.
To this the feeble pulsation, or its complete absence in the arteries
of the limb, are to be added, and no difficulty will be experienced
in recognizing the disease. In its early stages the diagnosis is
more difficult. "
The following case is from Cruveilhier: — " I am aware of a case
in which the mistake lasted much longer. The nature of it was as
follows: — A man, (54 years of age, was admitted into the surgical
wards of an hospital, for lancinating pains, with sensation of cold in
ft Dublin Hospital Reports, Vol. v., p. 17.
Dk. Gordon's Reports of Rare Cases. 345
the toes of the right foot. No one in the least suspected a
threatening or existence of gangrene. An endeavour was made to
restore the sensibility by sinapisms, and the introduction of acu-
puncture needles. The patient, being phthisical, was transferred
into a medical ward. There it was still supposed to be an ordinary
case of paralysis <>(' the lower extremity, and it was not for several
davs after, thai the true nature of the disease was discovered, when
to the insensibility and coldness of the limb, discolouration was
superadded.'1
1 1 is clear, then, that cases of arterial obstruction may be mistaken
for paralysis; and it may be worth consideration what are the
symptoms which arc so constant as to give rise to this error in
diagnosis.
We iind first, as in this case, complete paralysis of sensation
and motion. The following are Cruveilhier's observations on this
interesting point : —
" If the arterial circulation be not completely intercepted in the
limb by means of the obstructing clots, nutrition is kept up ; but
sensation and motion may be either diminished in it or completely
abolished, and that either for a time or permanently. I am not
aware if there are on record cases of permanent paralysis from
arterial obliteration Avliich have not been followed by gangrene ; but
it is very requisite to distinguish paralysis of sensation and of motion
arising from incomplete stoppage of the arterial circulation, from
what may be properly termed gangrene, or more properly from
paralysis, which is the first symptom of gangrene ; and the more so
because this paralysis, connected with gangrene, comes on suddenly,
in a moment, and is often unaccompanied by any change of colour
in the skin, or any of the physical signs of gangrene."
He then relates how it once happened to himself to be called to
sec a woman, about 40 years of age, the subject of a cancer in the
breast, who had all the morning been walking about her room as
usual, when she was suddenly seized with complete paralysis of sen-
sation and of motion in the left upper extremity. " I confess,"
he says, " that I thought I had to do with an ordinary paralysis.
I had the limb rubbed with spirit lotions, and then wrapped in
warm flannels; but after some time, being struck with the cadaveric
aspect of the limb, and seeing that in some places the rubbing had
taken off the cuticle, I saw my mistake, and I pronounced it to be
a form of gangrene which I have since called ' gangrene by cada-
verisation,1 and which the event but too fully confirmed."
Db Gordoi
B find this pa. Jso in tin |
mpanied !■ tin in the limb, which ma) be
;en for neuralgic pain. This poinl i- ako irdl illu I in
ruveilhier'a Pathology.'1 A. lady, sixt; was
bled in tin- h 1 1 arm for a pneumonia. Four hours after the vena-
tion she seised with acute pain from the points of tin- fin-
to the bend of the elbow on the suur side, with paralysis of sensation
and of motion of the hand. The lady referred the paralygifl to the
bleeding, and thou- lit that a nerve had been wounded. The next
day Cruveilhier Baw her, and found the paralysi isation and >>\
motion confined to the left hand. She eould no: ' »ly either tlex
or extend the wrist, and was complaining also of excessive pain in
the fingers. I considered (I: I the paralysis to be confined to the
hand; that this combination of paralysis and pain had its .-eat not
in the brain, but in the nerves of the hand; and that this cause was
a rheumatism, fixed in the cutaneous and muscular nerves of the
hand. However, having discovered that the pulse was not to be
felt in the affected side — that the radial artery was small, hard,
and painful on pressure, 1 added to my note that the paralysis,
purely local, was rcl'errible either to a lesion of the nerves or to a
lesion of the arterial system. The following day gangrene took place.
These arc the points which make the diagnosis difficult in the early
state — the suddenness and completeness of the paralysis of sensation
and of motion, and the intensity and perseverance of the pain. In
some cases the pain precedes the paralysis by some days — a circum-
stance which is even more calculated to deceive.
The means of diagnosis on which we have to rely are briefly these : —
1st. That the paralysis from arterial obstruction is always accom-
panied with coldness of the limb, and a peculiar whiteness of the
skin, like to that of a corpse : the limb is, in fact, deadened. To these
Cruveilhier adds that, in this form of paralysis, the absence of sensation
and of power of motion is, to use his own form of expression, as
complete as possible; whilst it is rare to see a complete paralysis from
lesion of the nerves. The finding the artery or arteries painful on
pressure, and like a cord under the linger, would, of course, complete
the means of diagnosis.
With regard to the immediate cause of these two prominent, very
formidable, and distressing symptoms — the intense pain, and the
paralysis with which the disease is ushered in. Acute pain appears
to be almost invariably connected with a sudden obliteration of any
part of the arterial system ; it enters prominently into the history of
Db. Gobdon's Reports of Rare Cases. 347
those oases where b large artery La obliterated by a mass of fibrin;
and is. in all probability, caused l>y (lie excessive sudden distension
of the coats of the artery behind the occlusion, which distension wo
know, in some instance's, to amount to actual rupture. Cruvcilhier's
experiments lead, I think, to this Conclusion, although the inference
he drew from them was different. When he injected mercury into
the femoral artery there was, at first, very little pain; but when, in
bort time, the main artery of the limb became occluded, the pain
was Intense, as he himself terms it, atroce, excruciating. The pain
clearly does not arise from inflammation, Cruveilhier, evidently at
a loss to account tor it, says it arises from a sort of struggle between
life and deatli in parts deprived of their means of nutriment.
The paralysis of motion and of sensation are, perhaps, more easily
Minted for. Passive motion of the limb causes great increase of
Buffering, so that it might be supposed that the want of power of
motion of the limb arose simply, as we see every day in cases of
acute articular inflammation, from the patient being unwilling to
add to his sufferings, and to which condition the term vital anchylosis
has been very happily applied. But this is not so; and, even if it
were, would not account for the absence of sensation. Both
phenomena are produced by the nerves being suddenly deprived of
arterial blood, their usual stimulus and nutriment.
The next point of interest in this case is the consideration of the
nature of the affection under which he laboured — wThether it was an
original active arterial inflammation, and if so, when this inflam-
mation commenced ; or were the arterial changes consequent on
other disease.
Before this boy was sent to school, he was badly fed, badly
clothed, and lived in very impure air — three evils which, when
combined, are certain to produce degeneration of textures, which, in
the present instance, instead of mere destruction of tissue, was led
by circumstances to take on the form of fatty transformation ;
which, as Williams observes, under whatever circumstances it
occurs, is obviously a process of degeneration or degradation to a
low BCale of animal or even vegetable life.
Post mortem examination showed that there was scarcely an or^an
in the 1 >< »dy which was not affected by this fatty degeneration, and with
the rest, the arterial Bysi em showed extensive marks of such disease.
If these adventitious growths (which, whether fatty or not, must,
a- I In rves, at all events l.e considered not as a local disease,
but as referrible to some constitutional cause), are capable of retard-
Di Gordo
the circulation, and cau ring deposit of fibrin in t! .
a- ire know they do in the aorta, how much more will thif be likely
to occur in the small ve [n thii way the circulation through
the capillaries of the right and Lower extremity itm retarded, and,
occurred in so many of Cruveilhier's experiments, whin the
circulation had been obstructed to ■ certain extent in the oapilhuri
and small sized arteries, there was then a Budden and complete
stoppage of the circulation through the main artery, accompanied by
the sudden accession of the formidable symptoms enumerated. The
different effects observable in the condition of the vessels above and
below a certain point in the leg, point clearly to two different
causes: from the aorta downwards was clearly coagulated arterial
blood; from the capillaries of the foot upwards to when1 the two
points met was also blood, but deposited slowly, under circumstances
more favourable for its decomposition.
The condition of the lungs was particularly worthy of observa-
tion. I had seldom seen exactly similar appearances, nor can I
find that they are of ordinary occurrence.
They presented somewhat the appearance of partly-wetted sponge,
but were not in the least softened or collapsed. They wrere of
a dark grey, or lead colour. When squeezed, they gave out a
quantity of thick, oily fluid, which greased the hands, and had a
peculiar heavy odour, but not at all like that of gangrene. When
cut, they presented a rough, granular section, and showed an
immense number of circular openings, more or less large, which
were evidently dilated pulmonary cells ; and in many of those were
found a similar thick, oily, but discoloured fluid. The appearances
were totally unlike those produced by pneumonia in any form, or by
any ordinary phthisical degeneration. I therefore conclude that
they were produced by an acute fatty degeneration of the pulmonary
substance — the same disease which pervaded almost every structure
in the body. It is now many years since Mr. Harney, of St.
Thomas's Hospital, described a certain form of emphysema of the
lungs, as originating in fatty degeneration of the pulmonary
membrane ; and it would appear in the present case that, in
addition to the air cells having become dilated by the degeneration
of their delicate lining membrane, there was a deposit of oleaginous
matter in the dilated cells.
Hasse seems to have met with such a case, and although he
a See post mortem examination of Case VII.
Du. Gordons Reports of Ram Cases. 349
attributes the appearances to pnsifmonta, he is evidently not satisfied
with bis own explanation of it. It ifl to !><• regretted that he docs
not give more particulars of t lu- ease, Hifl account of' it is as
follows: —
" In an instance of Considerable emphysematous dilatation, in a man
who died of pneumonia, the diseased patches of 1 1 1< Lung presented
such peculiarity of appearance, that I at first entertained doubts re-
specting the real nature of the malady. The cut surface appeared
as if besprinkled with dull-yellow granules of irregular shape, mostly
the size of hemp seed, and of the consistency of soft butter or thick
pellets of pus. These granules imperfectly filled little smooth
cavities, likewise of irregular shape. They might have been mis-
taken for tubercles: all doubt, however, was removed by their
aspect, their seat in pulmonary cells obviously dilated, their gradual
transition into the ordinary bronchial mucus, their occurring at the
anterior portion and at the margins of the inferior lobe of the right
lung, and in the midst of gray hepatization (presenting in a con-
spicuous manner all the gradations from undilated to thoroughly
emphysematous parts), and finally, by the fact, that no tubercles
were discoverable elsewhere ; to which may be added the symptoms
observed during life."
It is rare to meet with such extensive fatty degeneration in any
one individual, but particularly in one so young. Cases of fatty
defeneration of the heart have occurred in children six and eight
years of age, and have been described by Barlow and Ormerod.
But in the present case, scarcely a tissue in the body appears to
have escaped its influence ; and while it appears to have made much
further inroads on other organs, its effects on the arterial system
were more directly fatal ; nor is it the least remarkable circumstance
in the case, the immense disproportion which was found to exist
between the small extent and degree of gangrenous action which
had taken place and the great amount of arterial circulation wdiich
was obstructed.
VII. — Case of Typhoid Pneumonia ; Treatment by Sulphate of
Quina; Death from Impaction of Fibrinous Concretion in left Pul-
monary Artery. — A labouring man, 40 years of age, was admitted
into the Hardwieke Hospital, on the 17th of February, complaining
of great oppression of his breathing, and pain in his chest, with
which he had been suddenly seized. His respiration was short and
rapid, his pulse small and frequent. lie was very weak; when
aired to -it up in bed he almost fainted; and his count
i whole manner indicated great prostration. 11 kin had
it yellowtinge, and tin re were a few very small petechia]
his bod} . He had thephj deal signs of solidification of at least the up]
half of the right lung, but Ik- had very little cough, and do expectora-
tion; coughing or deep inspirationincn reatly the pain in hi
The treatment pursued was the administration of calomel, opium,
and James' powder every three hours, with repeated applications of
spirit of turpentine over the affected side, lit- said that he t
perfectly well five days ago, and that his illness was brought on by
continued exposure to wet and cold. On the 19th there was no
perceptible improvement, the calomel and opium was discontinued,
and he was ordered rive grains of sulphate of quina every three
hours. On the 20th his pulse had fallen from 128 to 116 in the
minute; on the 21st to 100, and he had begun to perspire copiously ;
OH the 22nd he appeared much improved; his pulse had come down
to 80, and his respiration to 30 in the minute; he eould inspire with
comparative freedom, and the sense of weight on his chest had quite
left him. The perspiration continued, and he took beef tea and
other light nutriment freely, and appeared to have escaped all
immediate danger. There was not, however, very much improvement
in the local symptoms. The bronchial breathing and bronchophony
continued, but there was vesicular murmur audible lower down in
the lung than at first, lie continued to improve on the 23rd; his
pulse had on this day come down to 70, and his appetite was
improving. There was now, for the first time, a very loud systolic
murmur audible at the top of the sternum. On the night of the
23rd, whilst sitting up in bed laughing and talking with a patient
beside him, he suddenly gave a loud scream, pressed both his hands
to his chest complaining of intense pain ; his breathing immediately
became excessively rapid and laboured; he broke out into the most
profuse cold perspiration; his chest heaved, gasping for breath; in
a few moments he had a slight convulsive fit ; vomited some brown
fluid, and his bowels were moved involuntarily; his lips became
blue, and his pulse, small and irregular, at length ceased altogether
The resident pupil Baw him immediately, and made no small
exertions to relieve him, but he sank with frightful rapidity, and he
was dead in less than a quarter of an hour from the commencement
of the attack. Such a history led me to expect that I should find
a rent in, or perforation of, some of the thoracic viscera ; but such
was not the case. I made a careful examination of all the cavities
Db. Gordon's Reports of Ran Cast 351
seriatim. The apper lobes of the righl lung presented so example
of a form of pneumonia which I had do me time. Jt
was 1 1 1 : 1 1 form which was epidemic in this city many years ago, and
which, from the peculiar colour of the lung, was termed "blue
pneumonia,'1 the pathology of which form Beems to consist in the
Mood vessels being distended with onoxygenated blood, which
excludes the air from the smaller air tubes. An accural ant
of its morbid anatomy and pathology will be found in the Transac-
tions of the Pathological Society. a In appearance it closely resembles
oarnified Lung, hut differs from it in the very material circumstance
of retaining its original bulk. Such was the condition of a consi-
derable portion of the right lung; of a blue colour, the consistence
and feel of muscle, it sank in water, but retained its natural size,
or was perhaps a little larger than natural. The lower portion of
this lung was slightly emphysematous, as was also the entire of the
left lung, although the pleural cavity at this side was obliterated
by old adhesions. The bronchial mucous membrane of both lungs
was highly congested.
On opening the aorta, at the distance of about half an inch
from the aortic valves, there were found two small spots of
rough lymph deposited on its lining membrane, and as if grow-
ing from it, these were found to be deposited on two spots of
atheromatous degeneration in the aorta, but there were no further
signs of aortic inflammation. The tricuspid valve was thickly
entangled with fibrinous exudation; this exudation wTas granular,
gritty, totally different in appearance and feel from fibrin a3
ordinarily deposited. There wTas also a small portion of the same
structure, about the size of a very small hazel nut, lying in the apex
of the right ventricle ; the right cavities of the heart were otherwise
gorged with black semi-fluid blood, which also distended the
pulmonary artery, and on opening up this vessel we found a large
mass of the same fibrinous substance, completely occluding its left
branch. This concretion, which appeared to be composed of a
peculiarly fine gritty matter mixed up with the fibrin of the blood,
formed a solid plug, completely closing up the left branch of the
pulmonary artery; beyond it the arteries were empty, while behind
it the right ventricle and auricle were full of black coagulated blood,
ami a large coagulum filled up the trunk of the pulmonary artery.
This coagulum, however, was of totally different consistence and
* Yi'h Trans. Pathological Society, Vol. i.; p. 53 ami 71.
Db. Gobd< >i
material from the fibrinous plu to; but ■ lubstancc similar
tu thifl latter, and about th f a very -mall nut, MTU found in
the apex of the right ventricle; an 1 a] o interlaced into the differ*
meshes of the tricuspid valve vras a Bunilar substance, with
masses appended; a section of these Bhowed that they under-
going a pr of softening in the centre. The abdominal i
6 healthy.
The brain, but more particularly its investing membrane, presented
very intei; Hilarity; there was not, however, any c.\tra-va.-eular
effusion whatsoever. The arachnoid membrane seemed perfectly
transparent and normal, nor WBfl there any subarachnoid effusion.
The foregoing ease presents at least two points of interest — Let,
1 would allude to the success of the mode of treatment by quinine
in this form of pneumonia, thus removing from it the grave charac-
teristic which it bore when first described by Dr. Corrigan, as " an
idiopathic form of disease characterized chiefly by an atonic state of
the vessels, and in which the symptoms were not amenable to any
of the usual modes of treatment." It is now several years since I
drew attention to the value of quinine in the treatment of typhoid
pneumonia, and a very extended experience since has confirmed me
in the remarks which I then submitted upon this very important
subject.3 I would now only allude to the fact of the apparently
complete recovery, as far as the general symptoms are concerned,
as evidenced by a slow pulse, normal respiration, complete freedom
from fever, pain, and dyspnea, while a considerable portion of the
lung still remains in such a state of solidity as to completely
exclude air. This fact was not new to me ; I had often recognised
it before, by the physical signs, but never had an opportunity
of verifying, by post mortem examination, the fact that the
Inner remains for so loiur a time so little altered from its diseased
condition. It has frequently occurred to me to find, even after
convalescence was apparently established, and the patient seeking
his discharge from hospital, that the lung still remained solid, evi-
denced by the persistence of bronchial breathing and bronchophony,
with dulness on percussion Such cases are very intractable and
difficult to cure ; persistence in the use of quinine, in the same or
modified doses, is useless, as is also the ordinary treatment by any
form of mercury ; indeed, I would go farther and say, that mercury
usually does much harm. I have more than once seen in such
a See Vol. xxii., p. 95.
Dk. Gordon's Reports of Rare Cases. 353
oases, treated with this mineral, symptoms of pulmonary phthisis to
supervene, and this disease to run an unusually rapid course; but
I have always experienced much advantage, and, in many instances,
i rapid cure, from change of air, counter irritation, and the adminis-
tration of iodide of potassium with bark: while the iodine acts as
a resolvent of the coagulated fibrin, the bark seems to exert its
tonic powers on the capillary vessels of the Lung.
Bu1 the second, and perhaps the chief, point of interest is the
mode in which this patient's death occurred.
On this point I would observe, that the substance found in the
left pulmonary artery was truly a fibrinous concretion — or, as it is
now commonly termed, an embolus, and not simply coagulated blood.
It fulfilled two of the four conditions laid down by the late Dr.
Hughes, under any one of which he considered " the evidence of
the fact decided and incontrovertible." First, it was entirely separate
and detached from the coagulum which filled up the remainder of
the vessel ; and, second, certain chemical changes, the result of
degeneration, were observable in the concretion, and which were not
to be found in the accompanying coagula.
I cannot, from this case, add much to the symptoms originally
laid down by Hope as diagnostic of this affection; but it bears
record most fully to the accuracy of his description: — " Sudden and
excessive aggravation of the dyspnea, without any other obvious
adequate cause ; the pulse small, weak, irregular, intermittent, and
unequal ; the patient, in agony from an intolerable sense of suffo-
cation, cannot lie for a moment, and continues tossing about in the
most restless and distressed condition, until his sufferings are ter-
minated by death. During this state, the surface and extremities
are cold, the complexion livid, and in most cases there is nausea
and vomiting of all ingesta." There were also present, in this
instance, the convulsive movements and stupor which Bouillaud met
with in a similar case.
The great rapidity with which death supervened was, of course,
owing to the large extent of the right lung which was already ren-
dered useless, by the state of solidification to which it was reduced.
The emphysematous condition of its lower portion, and of the left
lung (although placed in such an unusual and unfavourable con-
dition for its occurrence) bore witness to the immense efforts which
nut ure made to readjust the respirator}' process. I have already
elsewhere alluded to this8 condition as constant upon fibrinous con-
" Vide Dublin Hospital Gazette, N.S., Vol. ii., p. 345.
\ I 'I.. XWIIl.. N<>. 66, N. S. G
1 )i: ( | iN'fi I'' i
:lit aide of the heart or Lungs, with which it
to be intimately connected
The diagnosis is uow comparatively mf/ull dischar
q the left the heart; and cases are almost dairj record
in which their occurrence has been recognised during Life, and
suitable treatment accordingly been adopted; but, inasmuch ai the
genera] signs indicative of their existence in, or discharge from the
right Bide of the heart occur in all cases in which there i- an extreme
obstruction to the circulation through the heart, whatever be
cause, the diagnosis of their occurrence during life, aa emanating
from the right side, is peculiarly difficult; so much so that perhaps
we are not yet in a position to predicate of their existence without
actual post mortem investigation. The following case, however, -till
under investigation, 1 have held forth as an example of this very
peculiar affection: —
VIII. — Case of Sudden Acute Bronchial Congestion, supposed to
hare its origin in the Obstructed Pulmonary Artery. — Anne Byrne,
a servant in a large dairy, was carried to the Whit worth Hospital,
on the 7th of March, in a state of collapse. By the aid of stimu-
lants, chiefly external, she was partly roused from this condition, and
we then learned that three days before she was in perfect health;
that without any known cause she found her breathing getting
short, and that this dyspnea hourly increased. On the morning of
the 7th she had a slight convulsive fit; and in the collapse con-
sequent on it she was admitted into the hospital. She was stupid,
listless, very drowsy; her face congested; lips blue; surface of the
body cold, and more or less livid. There was no complete parah
of sensation or of motion ; but her limbs retained no strength; she
could not be put in the erect or sitting posture for a moment for
fear oi' syncope. The radial pulse was extremely weak, and the
heart's action was feeble, wavering, and almost imperceptible; no
cardiac sound, normal or abnormal, could be heard; but a deep,
loud, sonorous rale permeated the entire chest, This sound
appeared to emanate from a point beneath the sternum, and from
thence to radiate in all directions ; the respiratory murmur was
scarcely to be heard in any part; there was no albumen in the
urine.
I had considerable difficulty in coming to a conclusion as to the
nature of this case. The symptoms were evidently produced by
the brain being gorged with venous blood; but this was clearly a
Db. Gobdon's Reports of Ran Cases. 355
secondary Lesion; it wm no ordinary case of bronchitia either in
symptoms or in physical signs. It resembled mosl a case of tracheal
obstruction: bu1 doI from a foreign body within the trachea, for,
first, there waa do history of the introduction of any such. Second,
the aymptoma did not Bupexrene Buddenly, but wen- three days
accumulating. And third, the respiratory murmur was equally
feeble, and the tracheal rale equally loud throughout both Lung
And. on the other hand, an illness of only three days was unusually
short for the arrmnulation of symptoms of* pressure from an
aneurismal or other such intrathoracic tumour as is ordinarily met
with.
I treated the case with external stimulants, warmth, and friction,
to restore the capillary circulation; blisters to the region of the
heart, and whiskey and ammonia internally.
She Blowly recovered from the collapsed condition, and, in propor-
tion as she did, her cough became very troublesome, and she was
more than once in imminent danger of syncope from attempting to
ail up in her efforts to cough. Great and permanent congestion of
the jugular veins was now superadded to the other symptoms, and
she complained of intense pain in her heart. She very slowly
amended until the 12th, when, after using some slight exertion she
fell back exhausted and apparently moribund. She was only aroused
by the momentary exhibition of a powerful carbonate of ammonia
emetic, which, however, had the desired effect of restoring anima-
tion, and in an hour after she was altogether in a better condition
than she had been hitherto. On the 13th she had another attack
of syncope, less severe, and from this also she was aroused by an
emetic dose of carbonate of ammonia. From this time she has con-
tinued to make daily progress; for several days she took six grains
of carbonate of ammonia every four hours, with large doses of wine
and whiskey. On the 21st she was improved considerably, natural
warmth and heat were restored to the surface ; her pulse was 120, but
on the least exertion it intermitted and failed in strength; her breath-
ing ia easy, and the cough much less. The treatment was altered to
chlorate of potass and chloric ether; wine and whiskey being con-
tinued. On the 10th of April she is convalescent; there is no
evidence of valvular disease of the heart.
I think the diagnosis was borne out in this CS&e par role d\\vclu-
'/, and by the fact, that a permanently distended pulmonary
artery does exert great pressure on the root of the trachea, imme-
diately above tin- bifurcation, the point whence the tracheal rale
G 2
DB 1) v.\k> ( 'I anal I:
in this case The non-arterialisatioii of the blood was, of
course, owing to the interruption in the pulmonary artery, not t<>
the pressure on the trachea. The mode oftreatmenl which proved
successful in this ,,U also, in my opinion, to confirm the
truth of tin* diagnosis.
AlM XVI. — Clinical Reports and Observations on Medical Cases,
By J. T. Banks, M.D., T.C.D., King'fl Professor of the
Practice of Medicine, &c . &C
Empyema — Paracentesis and the Employment of the "Drainage"
tube. — To all who are versed in the history of medicine it is well
known that the operation of thoracentesis is one which has num-
bered among its advocates some of the most successful cultivators
of the healing art, and it is also matter of notoriety that, owing to
one of those revolutions from which even physic is not exempt, it may
be said to have for a season fallen into comparative disuse. However,
it is again enjoying as high a place in the estimation of practical
physicians as at any former period, and it is now resorted to with a
confidence in its remedial power fully equal to that which was
evidently entertained by practitioners of the olden time.
The recorded cases and observations of eminent physicians at
home and abroad have largely contributed to this result, and it
is now adopted in many cases with a well grounded hope of success,
while in others the not unimportant end is attained of alleviating
pain and suffering, and prolonging, though we cannot save, life.
That in a great number of instances the failure of the operation
was owing to its being postponed to too late a period, I am perfectly
persuaded. The early operation — that is to say, as soon as all
reasonable hope of the fluid being absorbed must be abandoned, and
before the lung is bound down by unyielding adhesions — is sometimes
followed by complete recovery ; but even when we cannot, from the
duration of the disease, look forward to perfect restoration of the
function of the lung, present danger may be averted, life may be
saved, and even years, in some cases, may be gained. Few physicians
who have enjoyed extensive opportunities of treating disease, taking
a retrospect of cases of pleural effusion, cannot refer to cases which
might have been saved if the operation of thoracentesis had been
performed, more especially if the system of drainage, first recom-
I ) i : Hanks' ( li ideal Reports. i 1 5 7
mended id chronic abscesses by M. Chassaignac, had been resorted
to.
There arc many cases on record, in which there was little more
than palliation of urgent >\ mptoms anticipated, bu1 which eventuated
in restoration to health. In reporting a case of empyema some
time since, I observed, "whatever difference of opinion may exist
as to the operation being called tor under ordinary Btates of pleural
effusion, there cannot be a question as to the propriety of it when
dyspnea is so argent as to threaten life. There are cases when
a few days of life arc of incalculable importance, and even
independently of this consideration, if we can render the few
remaining days of life comparatively comfortable and free from
Buffering, and that this great gain can be obtained by a trivial and
almost painless operation, surely wc ought not to hesitate." The
experience derived from the observation of many cases warrants us,
although ultimate recovery is not always a probable event, in holding
out the expectation of lengthened days. Legroux performed in one
ease 24 successive operations. Wunderlich, in his Ilandbuch der
1'athologie und Therapie, relates a case of empyema in which he
operated three times in the course of six months; before each
operation death appeared imminent, but the operation had the effect
of prolonging life for one year, at the end of which death ensued,
not however from the original malady, but from consecutive
Bright's disease. Age, even advanced, should not preclude the
operation, or lead us to despair of a prosperous issue ; the same
author reports two examples of successful result from the operation
of thoracentesis in aged persons, one of whom he saw many years
after in perfect health.
There are cases in which, from the duration of the disease, we
cannot expect expansion of the compressed lung ; but still life may
be prolonged when a fistula is established. Dr. Wendelstad, of
BEersfield, who was himself the subject of the operation of thora-
centesis, at the end of 13 years placed his own case on record in the
Journal der Practischen Heilkunde. For this lengthened period the
fluid was drawn off twice each day; sometimes as much as three
ounces flowed away, and at other times not more than half-a-drachm.
After 1" years, anxious to determine the capacity of the chamber, he
injected it with warm water, and found that it was capable of contain-
ing <mc quart ; the chest had fallen in and was motionless ; bul he could
blow the flute, walk feet, and. when he published the history of his
ease, he had been for many years again engaged in active practice
Di: B INKS ( linical Ripci
i physician. How much longer In- liv< »l we have do means of
Brtaining. The operation of tapping tin- cl wrionally
formed in of pneumo-pyo-thorax, when the disc the
consequence of perforation of the pleura in tuberculosis of I
lung. How desperate such c re, oft-repeated experience in-
forms as; but, nevertheless, Lasnnec says, " We must not abandon
all hope of cure, even when then- exists bo serious a complication
as this, provided there be no evidence of cavities in the opposite
lun Although, in the great majority of cases of perforation of
the pleura, the consequence of tuberculosis of the lungs, or gangrene,
there i^ a communication established with the bronehi, still, we
should remember that a tubercle on the surface may be the cause of
the lesion, and the effusion of air be the result of the opening of
icles, as in the ease of rupture in emphysema. Of this form,
Louis has given some examples.
The following ease will illustrate the truth of some of the fore-
going remarks, with reference to the value of the operation of
thoracentesis: — A boy, aged 14, was admitted into Sir Patrick
Duns Hospital on the 11th of April, 1801, labouring under
pleural effusion of the right side; he was one of a family ot Beven
children, all of whom were remarkably healthy ; both parents
are alive; the father is, and has always been in good health; the
mother generally delicate, and has had repeated attacks of bronchitis.
The subject of this report had measles and scarlatina in childhood,
but recovered perfectly, no delicacy remaining behind ; at the age
of seven he had hooping-cough, after which, for one year, it is staled
that he was delicate, but, at the end of this period, his health was
Completely re-established, and he continued well until three weeks
before his admission into hospital, lie is very intelligent, and he
gave an accurate history of his present illness, lie said he was well
previously; that he shivered, and soon after was attacked with
severe pain in the right side. The ordinary symptoms of pleuritis
followed. For some days before he sought admission into hospital,
his respiration was gradually becoming more laboured, and finally
the difficulty of breathing became extreme.
The pulse was 132, and the respiration 40 in a minute. On
examination of the chest, the right side appeared larger than the
left, and, on measurement, it was one inch larger; the intercostal
spaces obliterated, and there was no motion. The sound, on per-
cussion, was dull over the whole extent of the right side, and the
dulness even transgressed the median line. On applying the hand.
Db. Banks1 Clinical Reports. 359
when tin* patient spoke or coughed, no vibration was perceptible,
and the respiratory murmur was absent, no sound being audible,
except bronchia] breathing at the root of the Lung. There wai
displacement <>f the abdominal organs the liver projecting below
the false ribs. The decubitus was <>n the affected Bide; any attempt
t«> lie on the kefl produced greatly increased difficulty of breathing.
The symptoms v. i re so urgent that the operation of thoracenl
was determined upon, and I performed it the day after the boy
came into hospital. As the fluid flowed, the respiration became
more easy, and he expressed himself wonderfully relieved. At the
end, the pulse had fallen to 112 and the respiration to 28. The
amount drawn off was four pints. The fluid was of a straw colour
and perfectly transparent. On the following day the respiratory
murmur was audible at the apex of the lung. There was a
remarkable amelioration of all the symptoms for about a week after
the operation, but soon it became evident that fluid was again being
accumulated, and at the end of six weeks it became necessary to
resort to the operation of tapping, and the result was in all respects
similar. The quantity and quality of the fluid being the same, and
the relief as manifest. Again the signs of accumulation gradually
showed themselves, and, at the expiration of four weeks, the
operation Avas again performed. At this period he passed from under
my care, and my colleague, Dr. McDowell, took charge of him for
three months, during which he remained in Sir Patrick Dun's
Hospital. The disease continued to run the course I have described.
After the third tapping the secretion of fluid took place rapidly,
and the symptoms were so urgent that it was found impossible to
put off the operation beyond a fortnight.
From Sir Patrick Dun's Hospital he was removed to the Whit-
worth Hospital, again coming under my care. Four weeks after
the last operation he was again tapped, and in five weeks the
operation was repeated now for the sixth time. The average
quantity was about five pints, and the fluid retained the same
character which distinguished it at first; it was straw-coloured
am, transparent, and without a trace of pus. In three weeks
the operation was repeated, and on this occasion the fluid was scro-
puruleut. The fluid rapidly accumulated, and the respiratory
distress was so great thai the operation was urgently demanded on
eighth day. The fluid was purulent, but Tree from disagreeable
odour. The ease appeared at this Btage likely to terminate fatally,
►me measure were not adopted to prevent the recurrence of the
Db BaNKI ( linieal li
effusion; the strength bad been latterly failing in ■ marked main i
and the respiratory distress Increasing. Under these circumstan
1 letermined to have a counter-opening mail*- in the chest, and ■
drainage tube introduced The operation was performed by my
colleague, Professor McDowell, on tin- 24th of October, L861.
1 was induced to have recourse to this operation from seein
report of "two cases of empyema illustrating the advantage «»t'
making two openings, and adopting the plan of 'drainage' in tin-
operation of paracentesis in that disease," by Dr. Goodfellow, of
London. On reading the history of these cases in the 42nd Vol
of Medico Chirurgical Transactions, I was convinced of the
advantage of the plan proposed, and that the case under my tare
was peculiarly adapted to it; it was, in point of fact, a much more
favourable rase than cither of Dr. Goodfellow's, and more likely to
terminate in recovery, particularly if the operation had been
performed at an earlier period, but I had not seen the report of Dr.
Goodfellow's cases until the boy had been tapped Beven times, The
question which we had to consider was, whether it was not too late
to expect any advantage from the drainage plan. However,
unpromising as the case was, I determined to give the patient a
chance.
Before detailing the further course of events in my case, I may
refer to Dr. Goodfellow's report. The first case was a boy of 17,
a member of a strumous family, who, at the age of 12 had measles,
followed by inflammation of the lung, terminating in abscess. lb-
had subsequently empyema, which pointed, and a large amount of
purulent matter was discharged. Upwards of two years after the
fistula was established, the boy came under Dr. Goodfellow's care,
who says that there was considerable emaciation, occasional hectic
flushing, legs and feet o?dematous, difficulty of lying in the recumbent
posture, frequent cough with copious purulent expectoration. The
affected side was flattened, and measured an inch less than the
opposite, the opening red, irritable, and discharging very offensive
pus. The physical signs were, dulness on percussion at the apex,
lower down a tympanitic sound, and below a dull sound which was
replaced by a tympanitic sound on his lying down. Amphoric
respiration, voice, and cough also existed. A counter-opening was
made in the chest, and the drainage tube introduced, and Dr.
Goodfellow says "the success of the experiment exceeded our most
sanguine expectations." The discharge, which was intolerably
stinking, was reduced in quantity, thick, and nearly free from odour.
Dr. Banks* Clinical Reports. 361
The improvement in his general health was rapid, the oedema of the
legs quickly diminished. Ai the <th I of three months the discharge
was reduced to two or three drachma in the twenty-four hours.
The second case given by Dr. G-oodfellow was one of the most
unfavourable which can be well conceived. Dr. Watson, who
saw the young man before his admission into the Middlesex
Hospital, concluded that he had pneumothorax, and that a com-
munication had been made between tin' lung and the cavity of the
pleura, in the progress of tubercular disease. He had had profuse
hemoptysis. Subsequently there was indubitable evidence of
effusion in the left pleural cavity, there was also evidence of
tubercular consolidation of the apex of the opposite lung. Dr.
Good fellow hesitated as to the propriety of recommending the
operation, owing to his belief in the tubercular origin of the
empyema. The lung had been compressed by fluid for more than
a year. The operation was however performed — paracentesis by a
double opening and the drainage tube. The result was similar to
the former; the patient gradually improved in health. This second
case is most valuable, as affording an illustration of the benefit
derivable from the operation, even under circumstances which might
well be looked upon as affording the least possible ground for hope.
Even, then, in pneumo-thorax with effusion, the consequence of
tubercular disease, operation is not only justifiable, but may in some
instances save life.
I have no experience of the effect of iodised injections in the
treatment of empyema, but the practice is strongly recommended
by Trousseau, whose opinion, on all subjects connected with practical
medicine, is worthy of the greatest respect. He reports three cases
of hydropneumo thorax, treated by paracentesis thoracis, and
injections of iodine, which have had a successful issue, (L? Union
Medicale). The injection which he uses is composed of equal parts
of water and tincture of iodine (5 grammes of each), with 2 drachms
of iodide of potassium. It appears to me that the iodised injections
might be employed with advantage in cases treated by the drainage
plan in the first instance. AVhcn the size of the original cavity has
been considerably reduced by the expansion of the lung and the
falling in of the chest, but that still the discharge goes on, the case
mighl be brought more rapidly to a favourable termination by the
withdrawal of the tube, and then washing out the cavity with tepid
water, and subsequently injecting with the solution. In my case
I have been thinking of having recourse to it. It is now more
Db Banks ( 'linieal I:
than fire months since the last operation mu performed and the
tube introduced, and there is -till about from two to thi
drachms of purulent matter ooming away daily. The cheel I
fallen in considerably. Tin- righl side measures one inch and ■ half
Lees than the left, the heart i- displaced, being drawn to the affed
side. Th( respiration audible in the upper region of the right
side, in trout above the nipple, and posteriorly over a like extent.
The left lung appears to be in a state of perfect health, and well
performs its function
There was one phenomenon noticed in this ease repeatedly, not
only f>\ myself, but by my colleagues, Drs, McDowell and Gordon,
namely, the presence of amphoric respiration, voice, and cough. This
is ;i confirmation of the correctness of Skoda's views on this subject.
lie does not consider a communication with the bronchial tul
essential to the production of resonance, but believes that the
vibrations of the voice transmitted through the pleura produces
oonsonating vibrations in the air contained in the cavity. In this
case there was not the slightest ground for suspecting a communica-
tion with the lung. No air existed in the pleura until after the
operation of thoracentesis.
In advocating the operation of tapping and the use of the
drainage tube in some cases, I do not wish to be supposed to under-
value the preparations of mercury and iodine, used both internally
and externally for the resorption of the pleuritic exudations. The
power of these remedial agents is well known, and fully appreciated,
but they will often disappoint, and then Ave must not postpone the
operation too long. Dr. Goodfellow would restrict the employment
of thoracentesis and the drainage plan to the cases of pleural effusion,
which may be correctly designated pyothorax. He would exclude
cases of serous effusion In this opinion I do not concur; and the
case I have before me is one in point. When, after we are satisfied
that there is no chance of absorption — the fluid collecting after each
operation — why wait until it becomes purulent? I believe the early
adoption of the drainage plan will give a better chance of success ;
and I mav mention that I have been in the habit of using Dr.
AVood's instrument for the purpose of determining the quality of
the pleural fluid, and it answers admirably as a means of exploration.
As to the general treatment of this case, which is still under my
observation, it will suffice to say, that it has been to the fullest
extent of a sustaining character ; the boy had the most nutritious,
diet, with a liberal allowance of wine, and for a very considerable
Db. Banks1 Clinic \l Reports, 363
period he bai taken cod liver oil. Ho is now steadily gaining
ground. He walks out daily, and lie is altogether in a most
satisfactory slate.
Touching his future, and that of similar cases, the law laid down
by Louis, and confirmed by the experience of Aran, is not con-
solatory, namely, thai uncomplicated pleurisy is always :>t the left
Bide. The latter goes so far as to affirm, that the existence of the
disease at the right side indicates the presence of tubercles in 95
cases out of a 100. He strongly advocates the operation of
thoracentesis, regarding it as one of the greatest triumphs of our
art, and one of the most powerful therapeutic agents we possess.
In conclusion, I have to observe, that the issue of this case and
of those published by Dr. Goodfellow, is calculated to inspire hope
from the operation when all other means fail. How unlikely was my
own case to turn out well, may be judged from the fact, that it was
suggested to me, that having recourse to the drainage operation
would be likely to throw discredit on the new plan — so unpromising
was the aspect of affairs.
My friend, Dr. McDowell, has favoured me with the following
notes of the operation and of his views as to the best manner of per-
forming it, which I consider a most valuable contribution.
In the case of Hill, the drainage tube was introduced into the
pleura in the following manner : —
" The cavity of the chest was directly punctured with a bistoury
between the fifth and sixth ribs, in the vicinity of the nipple, and
about the same place where paracentesis had been repeatedly per-
formed, both by myself and by Dr. Banks. Thin pus escaped in
considerable quantity; a 'bullet probe,' about 10 inches in length,
to the eye of which the drainage tube was fastened, was then
introduced, and directed towards the point where the counter
opening was intended to be made; owing, however, to its length
and slender construction, the instrument could not be made to press
against the parietes with force sufficient to enable it to be felt with
the finger from without. A steel sound was, therefore, introduced
instead, and with this instrument we found that the interior of the
pleura could be satisfactorily explored. The point of the sound was
now pushed against one of the lowest of the intercostal intervals,
and could be plainly felt whenever the handle of the instrument was
depressed; a small incision was then made over the rounded end of
the sound, which was pushed through the opening from within. It
was then evident that the solid sound, however suitable as a guide
Db Li okb on a DoubU bell Ststk
for making a counter opening, wm not adapted for completing the
bred object, m the drainage tube could not be attached to it; it
wwt therefore withdrawn, and the Long probe, tinned with the tul»<-,
was again introduced, but great difficult) wm experienced in findi]
the second orifice. After Borne delaj the probe iras at last guided
to the opening, on a director being introduced from without to meet it.
Prom the anexpected difficulty which was experienced in finding the
second orifice from within, it is obvious that the instrument which
is employed in the first instance as ■ guide for the counter-openir.
should he such as will allow the drainage tube to be fastened to it
when it is made to project through the pleura; BO that, on its being
withdrawn, the tube which follows in its track would be left in situ.
A ' Brodie'e Catheter' would, I believe, fulfil every indication; and
should I have occasion again to perform this operation, 1 would
proceed in the following manner : —
11 A direct opening being made into the pleura in front, with a
bistourv, the catheter would be introduced; the cavity could then
be rapidly explored, and the position of the upper surface of the
diaphragm determined. Guided along the surface of the diaphragm,
the catheter would thus be directed towards the outer and Lower part
of the chest, and the point made to press against an intercostal
interval, as near the diaphragm as possible, BO as to be felt from
without. A * Brodie's Catheter,' being furnished with a broad flat
handle, would admit of this very essential part of the proceeding
being done with great facility. The counter-opening would then be
made by cutting on the point of the catheter sufficiently to allow it
to be pushed through the wound. The drainage tube being attached
by a silk thread to the eyes of the catheter, on withdrawing the latter,
one end of the tube would be carried after it into the pleura, and out
at the opening which was first made."
Art. XVII. — On a Double-bell Stethoscope.
By Robert D. Lyons.
The frequent necessity of comparing and contrasting sounds of
delicate character at opposite sides of the chest, or in different portions
of the vascular system, led me, some years since, to invent a form of
double stethoscope, which appears to me to possess some practical
advantages in diagnosis of both heart and lung diseases.
Dr. Lyons on a Double-beU Stethoscope.
305
Inspection of the accompanying figure will readily convey an idea
of die form and uses of this instrument. It is fashioned ingutta
percha, and, being somewhat flexible, easily admits of adaptation of
its two hells to the parts about to he examined.
A little practice will enable the observer to distinguish the sounds
conveyed by the two branches of the instrument respectively. Sounds
emanating from opposite or distinct points can thus be submitted to
careful comparison and analysis by the same ear. The comparative
tone, intensity, duration, and other characters of pulmonic, cardiac,
or vascular sounds, can thus be judged of with perfect accuracy.
The following are some of the purposes to which the double stetho-
scope may be applied : —
The estimation of the comparative force, intensity, duration, loud-
. and other acoustic characters of the inspiratory or expiratory
sounds, in the supra or infraclavicular spaces, in cases of suspected
phthisis in the now so-called pretubercular stage, and in which very
slight departures from the normal condition of the respiratory sounds,
in one or both of the lung apices, are the only phenomena to be
expected.
1 at will |
I hands
<--pirat
Ml in
which deeply-seated tamo i
nature, mi I ad in which, by preasur*
bronchos, they produce inequaliti respiral ....
or throughout the wh
Incoiupa: I estimating the character- ut'thc aortic I DM
.•ids in inspected f\alvular or aortic lesion, Of in Ca?c.» in
which aneurUmal dilata: i tual aneurism exists. The phen
of two distinct pulsatile centre- within the cavity of the chest, with,
rare, sounds ami bnpu very distinct charad
can thus be most strikingly demonstrate
Aneurism, or other piil-atini: tumours in the region of the nee!,
axilla, in the cavity oi' tl. men, or in the iliac or femoral n g
can likewise he submitted to careful acoustic analysis by the doable
and the intensity or other character- of these phen
can be thus, with the u ..-curacy, contrasted with those of the
heart or the aorta.
Many other applications of the double stethoscope will, doubt.
occur to the practical physician.* A modilication ot' the double-bell
thoscope, in which the bells are made of the form of an elongated
ellipse, will be found useful in exploring the chest, when much
emaciation exists. A similar modilication of the ordinary single-be]]
e ha? been effected at my instigation. It will be found
. enient for the examination of phthisical patients, or otl.
in whom there is much ition, as it adapts itself readily to the
intercostal depressions. The elliptical bell is also well adapted to
the acoustic examination of arteries and veins.
* TL .:nent was first manufactured ^1S49> for me, under the superintendence
of the late Mr. Kane, whose preniat... rtly afterwards, chemical science
in Ireland ha to deplore.
PART II.
REVIEWS AM) BIBLIOGRAPHICAL NOTICES.
Sulle Mobutu da Fermento Morbifico e Sul loro Trattamento.
Mciiioria del DtB. Giovanni PoLLI. Milano. 4to, pp. 60.
On Disease* Depending on Morbific Fermentation, and their Treat-
ment. Memoir of Dr. G. Polli. Milan.
The work before us is a most interesting monograph on zymotic
diseases, strictly speaking ; or, on such diseases as date their existence
from the presence of a fermenting or catalytic principle, either
generated spontaneously in the system, or introduced from without.
Among zymotic or catalytic diseases, are classed almost all the
most fatal maladies to which the human frame is liable: cholera,
typhus, puerperal fever, glanders, black vomit, dissecting wounds,
marsh fevers, &c., &c. If the authors experiments can be relied
on, and they seem to have been conducted with great sagacity and
care, such diseases would be no longer fatal, they would be as
amenable to treatment, as many other ailments of daily occurrence,
and of which we take but little note ; and the remedies which cure
those fatal diseases, when developed, woidd, in addition, seem to be
capable of acting as prophylactics against them.
If Dr. Polli's investigations are correct, and his results unques-
tionable, a new era opens out in the history of medicine; and as
vaccine banished small-pox from the civilized portions of Europe,
so would the adoption of his remedies, render an army safe from
the devastation of typhus; a military hospital from the scourge
of infectious gangrene; a Lying-in establishment from the dreaded
puerperal fever; and the public schools from the ravages of
iatina. The BubjecJ is of such importance, that we shall
ali.-tain. IS much from comment, and rather give to our
readers in a condensed form, and, as far as we can, in the author's
L I B liographical A I
own vrords, an Recount of hif labours, his invi ad nil
experiments.
Dr Poll] commenoei bj establishing the great important
fermentation in catalytic actions, b< : —
uBj catalysis, fatty principles which are insoluble, arc rend I
soluble (glycerine, for instance); some bitter principl< talicine, arc
rendered sweet (glue >me inodorous substances, myrotic acid, for
instance, are changed into odorous essences (oil of mustard); many
neutral substances, as urea and allantoin, are changed into energetic
alkalies (ammonia); sonic inert principles, or of weak nutrient capacity,
-larch, are changed into inebriating BubstanCSS (alcohol) ; and, finally,
some principles of very slight action on the human economy, BS amygdalinc
are changed into energetic poisons (oil of bitter ahnomU and pruf
acid)."
Further on he says: —
"Different putrescible organic substances will, therefore, be capable of
producing divers morbific ferments; or, perhaps, even the one organic
principle, during different stages of its decomposition, may be capable of
producing the same varied effects; and if, in a healthy animal, some
BUCh putrescible substance should be introduced, either by the lungs, the
-tro-enterie tube, or by the cutis, or by injection, or by inoculation,
such substance being in a state of decomposition, different from that
which should correspond with a normal physiological metamorphosis, its
introduction would give rise to serious disturbance in the composition of
one or more of the fermentable components of the body; in such cases
the morbific ferment would be introduced from without. But should the
natural metamorphosis of the putrescible substances of our organism
deviate from its normal course, either in consequence of atmospheric
vicissitudes, great fatigues, insufficient exercise, mental anxieties, or in
consequence of suppressed secretions or excretions, such deviations may
give rise to compounds capable of effecting abnormal modifications in the
putrescible components of our body, and in this case the morbific ferment
would originate within the living frame The change which
takes place in the human economy, in either of these cases, is simply due
to a catalytic action; I shall, therefore, for the sake of brevity, and also,
at the same time to indicate their proximate causes, name all diseases
arising in such manner catalytic diseases. Catalytic diseases are truly
diseases of blood poisoning, for it is in the blood that the morbific
ferments are generated, or introduced I shall illustrate this
operation by quoting some experiments of Schmidt {Ann. di Chim. appl.
alia Med., vol. xxiv., p. 59). Blood, fresh drawn from the vein of a
1Y>lli on the Utff of l>imlphite$ in Zymotic Diseases. 869
healthy man, will not cans*; either sugar, urea, amygdaline, nor asparagine
to ferment It' the same blood in- Left exposed to the air tor a few days, a
principle will develop itself in it, which will be capable of determining
alcoholic fermentation in saccharine substances ; ami after fourteen (lays'
exposure another principle, capable of causing both urea and asparagine
to ferment, will be formed. Such blood, however, kept ever so long,
will not become capable of inducing amygdaline to ferment.
*• Blood drawn from the veins of persons labouring under various
diseases, including cholera, induces fermentation in a few hours, not only
in sugar and urea, but also in amygdaline.
"Prom these experiments I conclude, that the albuminoids of the
blood, can, under certain conditions, undergo such change as to give
origin to specific ferments, which do not exist in normal healthy blood;
and that during certain diseases, it not only has a greater tendency to
produce these ferments, but will even give rise to others, both different
and more active, than such as would arise from the simple spontaneous
alteration of normal blood.
" Experiments carefully practised on animals, have given the following
important results : —
" 1st. That the injection of a certain quantity of pus into the circula-
tion, produces pyemia, and such diseases as are characterised by multiple
abscesses.
"2nd. That the injection of putrid matter, produces septicemia, or
those diseases recognised by the name of putrid infections, and which are
characterised by typhoid gastro-enteritis.
" 3rd. That the injection of matter obtained from contagious diseases,
glanders, for instance, will reproduce the same affections.
" The injection of from two to four grammes of corrupted human pus,
into the veins of a dog of medium size, and weighing about six or seven
kilogrammes, almost always induces vomiting, after a few moments,
often followed by alvine dejections. The dog looks stupid and weary, and
stretches itself on its side, its breathing gets hurried, it will neither eat
nor drink, and thus it remains for two or three days. If the lesser
quantity (viz., two grammes), of pus have been injected, then the dog,
about the third day commences to improve ; it will take a little food, will
move itself a little, and altogether look more lively, and by the ninth or
tenth day, it will be so much better, as to be considered quite con-
valescent ; the wound also, through which the injection was practised,
and which, at the commencement, had suppurated and spread itself, will
now haye begun to get small, and will show symptoms of cicatrization.
If, however, the larger quantity (four grammes) shall have been injected,
the dog will become daily worse, presenting all the symptoms, and
running through all the stages, of typhoid fever; it will keep constantly
lying down in its kennel, in a sort of stupor; it will take no food; it
VOL. XXXIII., NO. 66, N. S. H
. •
often raffe] - from bloody stools; tin- wound through which the in
was praoti omes livid and gangrenous, and the dog di
the fifth ami seventh day after the operation. At the \
initiation the gastro-enteric tnbe it found in ■
inflammation, the mucous membrane ol a dark red colour, here and t!
dotted with puriform exudation, at timet mixed with nlcerat*
i > tcially in the neighbourhood of the pylorus, and in tin- cecum;
the lungs are found full of ecchymotic spots, and the blood contained in
the larger vessels, and in the right cavities of the heart, is tarry and
liquid.
be injection of from om- to three grammes of putrid blood, into the
veins of a dog, produces a typhoid disease, very similar to that produced
by the injection of pus, but of much more serious character. If the
quantity be injected, the dog rarely vomits, but remains stupid and
motionless, standing on its four legs, hanging its head down, and will
remain so, at times, for hours; eventually it lies down, and for several
days it will neither eat nor drink, the wound, during this time, becoming
large, livid, and sanious. By slow degrees, in the course of eight or ten
da\ 9, the dog improves, but during its entire illness, its complete prostra-
tion of strength, together with its comatose state, fully reeal to one's
mind the characteristics of adynamic fevers.
"If, however, the larger quantity of putrid blood, viz., three grammes,
have been injected, the dog both vomits and defecates, generally within
a few minutes, and the successive conditions of stupiditv. prostration and
coma, are more strongly marked; the dog lies on his side, with his legs
Stretched out, as also his head and neck; the wound assumes a sanious
and often a gangrenous appearance, and about the third, fourth, or fifth
day after the injection, the dog dies. At the post-mortem examination
the entire gastro-intestinal tract exhibits the appearance of a violent
attack of gastro-enteritis, the mucous membrane of the stomach and the
intestines being deeply injected, dark red, and in some spots ecchymotic
and bloody, the most inflamed portions being the stomach, in the vicinity
of the pylorus, the duodenum, and the rectum.
"The injection into the veins of a dog, of the discharge collected from
the nares of a glandered horse, even where only the small quantity of
half a gramme is used, gives rise to the following phenomena. Imme-
diately after the operation the dog generally vomits, this is followed by
utter prostration of strength, laboured respiration, distaste for food, rapid
wasting away, the formation, here and there, under the skin and
between the muscles, of numerous unhealthy (marciosi, putrid) abscesses,
which, when laid open, exhibit a lardaceous base, analogous to syphilitic
ulcers in the human body ; after death numerous clots are found in the
lungs, much more numerous and better marked than in the case where
pus was injected. These are not merely ecchymotic stains, but real clots,
Poll] on the Use of Bisulphites in Zymotic Diseases. ''>71
often softened in the centre, and even at times converted into purulent
ca\ hies.
"The summary conclusion of my experiments, of which I have now
only given s slight sketch, is, therefore, thai by means of injections into
the Mood, with the above mentioned morbific matters, very serious and
well marked forms of rtisonnfi can be produced, exhibiting all the general
characters of catalytic diseases."
Once admitted, that catalytic diseases depend on the presence
and action of specific ferment* in the blood, the question then
arises, whether it would be possible to neutralize them, and render
them inactive, when once introduced or self-developed in the
living body. Dr. Polli answers in the affirmative, notwithstanding
the assertion of Claude Bernard (whom he calls the greatest living
physiologist), who, after establishing the fact, that fermentation
may arise in the blood, and give origin to poisonous principles,
which may, in their turn, produce certain grave accidents in the
living frame, adds: — " La neutralization des ferments est impossible,
parce que pour cela, il faudrait changer les proprietes du sang a tel
point, que la vie ne serait plus possible (Lecons sur les effets des
substances toxiques et medicamenteuses, p. 99)."
Dr. Polli believes that we possess in sulphurous acid, when
combined with salifiable bases, a means of controlling and neutraliz-
ing morbid ferments in the blood of living animals, without, in
any way, vitiating its qualities so as to render it incapable of
maintaining life. After carefully studying the action of sul-
phurous acid, on organic matters, and fermenting principles, in
particular, our author came to the conclusion, that not only it
alone, but also its combinations with earths and alkalies, such as the
sulphites of soda, postash, magnesia, and lime, possess, in a supreme
degree, the power of arresting all known organic fermentations, and
putrefactive metamorphoses of animal solids and liquids; and that
it- action does not depend on its decomposing the fermenting prin-
ciple, but simply by modifying its molecular aggregation, so that it
never acts as a poison on the living organism, as do many other
Bubstanoes, well known for their antiseptic properties, but which,
on account of their poisonous effects, can not be employed with
safety. I [e says ■ —
"I made several experiments with healthy dogs, for the purpose of
determining the quantity of Bulphites of soda, potash, magnesia, or lime,
which could be safely administered, and I found that a dog weighing
H 2
372 R viewt and Bibliographical Notice*.
from wren fco eight kilogrammes, oould not only take, with perfect ^i<-ty,
from one to fifteen grainn .«ti Salts, but alfO without the slight
inconvenience ; and a dog of about the same weight, took daring fifteen
successive days, as much as ten grammes <>i th< ti daily. Sulphite
of lime appeara to be even better tolerated, as on one occasion ! . t>>
a dog of about eight kilogrammes freight, aa much ai fifteen gram]
it at a dose, and it did nut appear to suffer tin- leasl inconvenience, I
killed several healthy dogs during these experiments, for the purpose of
examining the state of their stomaeh and intestines, and I constantly
found them in a perfectly normal condition.
"Having thus determined the harmless action of these salts, I en-
deavoured to trace their course through the living organism, and
determine, if possible, by what way, and in what condition they I
eliminated from the system, and I found that they remain as sulphites
much longer than might have been supposed, from their aptitude
to become sulphates during the oxidizing process of life. I found
sulphites in the urine, for many hours after their ingestion, and not
sooner than after a lapse of twenty-four hours did I find them in the
urine as sulphates. The following experiment will prove interesting ; — I
took three dogs in good health, and of about the same weight and stature,
to one I gave fifteen grammes of sulphite of soda, in the course of twenty-
four hours, one gramme at a time, wrapped up in a pellet of sausage
meat ; to another I gave fifteen grammes of sulphite of magnesia, in
the same way ; and to the last I gave the same food, but no sulphites.
The three dogs were put to death at the same time; I collected the blood
and the urine of each separately, together with the liver and one hind
leg, without the skin ; I easily detected the presence of the sulphites, in
every one of the fluids and solids of the dogs to whom they had been
administered, while I failed in detecting even a trace of sulphurous acid
in the remains of the third dog. All these samples, liquid and solid,
were then left exposed at a temperature varying from 12° to 15° centi-
grade, and after five days the urine of the third dog exhibited a highly
ammoniacal odour, and its liver and leg gave evidence, by their smell, of
impending decomposition, while those parts which had been taken from
the dogs who had received the sulphites, still remained perfectly fresh."
These results confirmed my theoretic opinions, and I concluded, that
if sulphites taken by the mouth, could so modify the tissues of a living
animal, as to give them the power of resisting, for a longer period, the
putrefactive fermentation after death, so might the presence of these
same sulphites in the living tissues, enable them to resist, during life, the
action of those morbific ferments which constitute the essence of
catalytic disease."
The author's memoir concludes with the details of sixty-eight
Polli on the Use of Bisulphite* in Zymotic Diseases. 373
experiments, made upon living dogs, which we <lo not think it
necessary to transcribe, they were carried on evidently with great
care; one half of the dogs experimented »>n, were left to the c-fli-cts
of the poisonous injections without any remedy being administered;
tin1 other half were (rented with sulphites. The results were
various, and that fact tends, in our minds, to increase the value of
these experiments. Two dogs, weighing respectively nine and four
kilogrammes, received each an injection of four gramme- of normal
pus, in their femoral vein. The largest of the two, during the three
days preceding the operation, took eighteen grammes of sulphite of
soda, and during the two days which followed it, ten grammes more.
For ten days the dog continued in very tolerable health, it then
began to refuse its food, became drowsy, and two days later it died,
in consequence of hemorrhage from the wound. The post-mortem
revealed a state of enteritis, and melena of the rectum. The
lesser dog got no sulphites, nor any other treatment, it became ill,
but after a few days began to mend, and on the tenth day might be
considered cured. This same dog, after having perfectly recovered,
was treated to a fresh injection, but this time instead of healthy
laudable pus, as in the last experiment, was injected with some
putrid pus, long kept. The wretched animal died in three days,
and at the post-mortem there was found inflammation of the lungs,
with scattered pulmonary apoplexy, and gangrene of the wound in
the thigh. Several dogs were prepared with different quantities of
sulphites, for several days previous to being injected with putrid
pus ; the result was, that those which had received the smaller doses
of sulphites died, while those who had been liberally supplied with
them recovered, and the rule seemed to be pretty constant, that the
more pus was injected, the greater quantity of sulphite was
required to antagonize it. Several dogs were injected with putrid
blood, they all, with one exception, died. Other dogs prepared with
sulphites and then injected with the same blood, all recovered, as
well as some dogs, who were injected with putrid blood, diluted
with twice its bulk of solution of bisulphite of soda. A number
of dogs were similarly treated, with the discharge collected from a
glandered horse, and the result was the same.
We have read this memoir with great interest, the reasoning is
plausible, the experiments crucial, the results most satisfactory;
ami averse as we most sincerely are to all kinds of torture, and
though we strongly set our face against vivisections, yet, in tins
case, we cannot refrain from expressing a wish that these ex-
■ B
periments, and analogous one*, ma} be Boon carefulrj
in order i" test their real value Not many months
I I to deplore the Iom of i highly promising young man, resident
pupil in one of »>ur '. hospitals, who died from dim
inflammation, from a puncture received in the discharge of his
duties. It" Dr. Polli'a experiments can be relied on, we bad a
remedy at band, which could baye Baved that young man- life
other practicaJ use, to which we would be glad to see th<
sulphites put, is the preparation of subjects for dissection. Very
rarely does the diligent pupil and assiduous dissector, go bhrou
his term of study, without Buffering, in Borne shape, from the
constant inhalation of the products of decomposition. In
wards the night chairs might alwavs have a certain quantity of a
solution of a cheap Sulphite in them; vast suppurating surfaces and
Cancerous wounds might be dressed with the same, in short, the u-
of these substances, when once proved to be efficacious, would be
as universal as they would be valuable. In conclusion we would
. that if the author has not deceived himself in his experimen
nor over-rated the value of these substances, but has really dis-
covered in the sulphites, a remedy for catalytic diseases, and a
prophylactic against them, he has conferred a boon as great, or
perhaps even greater, than did Jenncr by his great discovery of
vaccination.
On Uncontrollable Drunkenness, relative to Medico-legal Arrange-
ments. Read before the Social Science Congress, 1801. By
Thomas Lewis Mai kest, M.D.
On Chronic Alcoholic Intoxication, or Alcoholic Stimulant*, in
connexion with the Nervous System. By AY. aIarcet, M.D.,
F.R.S., Fellow of the Royal College of Physicians, &c. London.
1860,
Some Facts which suggest the idea that the desire for Alcoholic
Stimulants is not only transmitted by Hereditary Descent, but that
it is also felt with increasing force from generation to generation,
and thus strongly tends to deteriorate the Human Race. A Paper
Reformatories for Drunkard*. ;>75
rad before the Dublin Statistical Society, <>n tli^ I5tb <>f
February, 1S5S. I > y .James Hai <.ii k >.\.
The City — its Sins and Sorrows, tyc. l>y Thomas Guthbde, D.D.,
Edinburgh. L857.
Reformatories for Drunkards. — Beyond all controversy it is
necessary that something should be done, if not to control and
destroy, :it least to prevent many of the evil results of drunkenness.
We may be met by the assertion that this vice is not so frequent or
so general as it was a century ago. Grant it for the moment; yet
nothing is better established than the fact that thousands are every
day rushing on to destruction, and involving the innocent and
helpless in most of the consequences of their lamentable propensity.
Regarding this, our national sin, Divines have preached; the
Legislature has enacted laws ; Sanitaiy Philosophers and Physicians
have written, taught, and practised; Temperance Societies have
laid down rides and administered pledges ; Orators have thundered ;
Parents have whispered, commanded, prayed; with what result?
very little indeed, if we regard the many and mighty agencies in
operation against it. Like other things in the world, most of these
agencies have failed, because along with truth they have inculcated
some fallacy.
The Divine denounces the continuous habit of inebriation as a
sin (which, in the first instance, it undoubtedly was in every case),
but he fails in the means he recommends for its cure — the forsaking
of it.
The Legislature enacts, that no crime is excusable because com-
mitted by the man when in a state of intoxication, but rather the
reverse; it punishes the drunkard in various ways, but the gaol
never teaches him to forsake his sin.
The Sanitary Philosopher comes very near the mark ; he inves-
tigates the many causes of this vice; he finds that some have an
undoubted hereditary tendency to it ; some are driven to the tavern
by the want of comfort at home;a a poor man because his home
is cold and dreary, his wife thriftless, his children are domestic
nuisances, his meals insufficient and badly prepared, because he has
no recreation there, nothing but dull misery always before him;
one of the " better class," as we term it, treads the same path to
* See Mr. Nugent Robinson's Essay " On the Condition of the Dwellings of the
Poor in Dublin, &c," read at the Social Science Congress, 1861.
vnd Bibliographical Notices.
ru'm beoau parents never think of youthful wad pursuits,
never trj to make hif home comfortable and a mor ible pi
to him than any other; or, perhaps, if a married man. because I * I -»
wife is a worthless idle woman, reads novels, lives in tin- clouds
■ complaining, but never realizes the world we all live in.
\ ain, this Sanitary Philosopher finds that the want of education
and public institutes for rational recreation and refreshment, i
fruitful source of drunkenness, the tavern supplying all these defed
that the wofully had education of most classes of women i- another
Cause, whether this he taken to mean education in the ordinary
meaning of the term or simply in housekeeping. The very know-
ledge of these causes supplies suggestions as to their remedy; yet
he tails, because these can only he carried out by public authority,
whether in the form of legal enactment or by the pressure of public
opinion.
Further, the Physician has taught, written, and practised on this
subject, lie may write and the public may read; he may strongly
recommend while the patient secretly evades his recommendations.
lie may treat cases of confirmed drunkards as those of bodily
disease, of mental, of both, of neither, of hereditary tendency, of
irresponsible agency, all with some measure of success; yet he can-
not enforce his advice or practice, and therefore, as we well know,
many of his patients relapse, and their end is worse than their
beginning.
Temperance Societies have laid down rules and administered
pledges; the good thus done is incalculable; they are right in
inducing men to give up sinful indulgence, but they err in enforcing
total and ascetic abstinence as the means to that end; they err in
describing alcoholic agents as poisons, as things which, under any
circumstances, or in the smallest degree, are injurious to health;
they err, in fact, in describing the moderate use of any of God's
gifts as sinful. An able writer says — " It is much more easy to get
the drunkard to abstain than to be sober. . . . Indeed this is so
notoriously the case, that all persons (however moderate their
morals), who have set themselves seriously to reform their characters
from habits of vice long indulged, are obliged (at least at first), as
a matter of prudence, to practise some degree of asceticism ; to deny
themselves certain lawful enjoyments in some circumstances, lest
old associations should draw them back into what is unlawful.
Men of discretion practise such exercises, not because they deem
the things forborne unlawful in others, but unsafe to themselves ;
I !r formal ories for Drunkards 377
in the Bailie way that the diet of a person iii full health is unsuitable
to the convalescent. But it is much more flattering to a man's
vanity (and therefore more agreeable to most persons), to believe
that the austerities, which his own previous vice and present frailty
render necessary, are themselves the highest and most perfect vir-
tue; that living in an hospital is the best indication of health."*
Temperance Societies err also, in affirming that abstinence (for it
is not temperance they want) constitutes a cure for drunkenness; as
well may one who has long imbibed some poisonous agent expect
that sudden abstinence from it will cure him. By no means; other
remedies, both medical and dietetic, must be adopted for this pur-
pose.
Against this vice Orators and Oratresses have thundered ; with
what effect? The great majority, like most people who hear good
sermons, consider the speeches very fine, the arguments very cogent,
the examples very horrible ; but there the matter ends ; no practice
comes from all the talk, and here, as in everything else, " man
thinks all men mortal but himself." Moreover, parents have whis-
pered wrords of caution to the erring son, they have commanded him
to abstain, have threatened, have punished, and, as a last resource,
have prayed the wayward child, by his love for them, by his fear of
disgrace, by his danger of losing reputation, by all his hopes for
this world and for the next, to give up the cursed indulgence
They have sent him to the world's end, he has come back unchanged ;
they have spent all their substance upon him, but their every effort,
every power, every prayer, has been in vain.
Now seeing that all these agencies have, to a lamentable extent,
failed to crush drunkenness, and so failed to prevent untold miseries
to the families of thousands, we hold that the time has come for
some institution or asylum to be erected, by authority of the legis-
lature, for the reception and treatment of confirmed drunkards. Let
it be called a lunatic asylum, for many drunkards are really lunatics,
as we shall presently show ; or, if that name be objectionable, let
the modern and more fashionable word " Reformatory" be adopted.
The principle for which we contend is, that drunkards who are
injurious to the lives and properties of themselves or others should
be placed under forcible restraint, and there kept until, by medical
and moral treatment, they are cured.
* Introduction to a Selection from Aristotle's Ethics. By Bishop Fitzgerald
(Killaloe).
rinciple oi a reformatory \v i 1 1 Ik- found to thii
pari icellency of the agencies alread
in their defects [f the drunkard be ;i i
who drinks irhen he could keep sober, it restrains him; if h<- be
physically diseased or poisoned b) long indulgence in the habit
that he must think to attain any degree of Comfort, it Dfl him,
wink' . i antidotes to the poison, treats hi- body for a di
ami endeavours to restore him to that soundness of health in which
will have no desire to indulge in this mere than in any other
kind of sin. If he he morally insane, that i- to -ay. reduced to snob
a state of mind that, contrary to his judgment, he feels compelled to
drink, it restrains him as a gaol can, hut also treats him a- being
oething else than a criminal, which a gaol cannot It will be
(bund, in tact, to embrace the functions of the Divine, tin- !
lator, the Physician, the Total Abstinence Society, the Temperance
Orator, and all the other means usually resorted to tor the attain-
ment of the Bame end. But these are such as relate only to the
individual. Look what advantages to society such an institution
would Becure ; property saved from destruction, the hopes and
prospects of families preserved from desolation, wives rescued from
.ertv, husbands from shame, children from beggary and disgrace,
with many others too numerous to mention, hut readily called to
mind.
This is one of the questions of the day. In t! i Ial Science
( Bgp 38 papers arc annually read advocating some BUoh measui
and if the writers differ as to detail this does not weaken the ease,
hut shows Btrongly what must he admitted to he the evident
disease, and the general agreement as to the principle of its treat-
ment.
But the question will be asked — "What classes of drunkards
will you commit to such Reformatory a Cases of delirium tremens
(from drinking) should not he so committed, because they fall within
the ordinary province of the physician, and are recoverable by
medical treatment. A second class is that of persons who, not
habitually but occasionally, get drunk at festive meetings, public
dinners, and the like. Now a man in such case is directly amenable
to the laws of God, of the land, and of good society: he is perfectly
responsible for his act. he cannot plead the force of habit, and even
though he should, from any given excess, get a fit of that temporary
mental derangement called delirium tremens, yet he, and all like
him, should be excluded from the proposed reformatory.
Reformatories for Drunkards, 379
With regard to the many who daily oon ume large quantities of
alcoholic drinks, without an} ill oonsequenoes save to their own
health, not even becoming intoxicated, though often taking much
more than those who become bo, it is plain that n<» legi lative inter
ferenoe is required, Of course such conduct lays the foundation of
many discuses, :uul transmits them to posterity; but in this oh e
the law cannot control or rule the man. Lei an) one read Car-
penter's pell Known Physiology of Temperance and Total Abstinence^
ami count by number the diseases induced by alcoholic excess, The
medical man will there see catalogued many of the ills the flesh i
heir i<>; indeed ii. ni.iy be i inly asserted that by far the greater
number of diseases are the fruits of intemperance, of our own mi
bridled passions, or of t lie sins of OUT fathers.'1
Here we are reminded of one large class of drunkards, those
who inherit a decided craving for spirit nous Liquors. Mr. dan
Haughton, in a paper read before t In* Dublin Statistical Society,
(February L5, L858), argues, that not only issuoh desire transmitted
b\ hereditary descent, " but that it is felt with increasing force from
generation to generation, and thus strongly tends to deteriorate the
human race." In (his paper he <piotcs, as an aul hority, Maenish,
in his Anatomy of Drunkenness » also Darwin, beside Mons. Morels
Physical) Intellectual^ and Moral Degeneration of ths Human Race;
Dr. Whitehead, On the Transmission from Parent to Off spring of
Worms of Disease i and of Morbid Taints and Tendencies', and The
Races of Man, a Fragment, by Robert Knox, M.D. 'The causes
which contribute to this deterioration are too numerous to mention
here. The mode of argument adopted is, that taking those coun-
tries where SpiritUOUS UqUOrS arc most consumed, we find the people
most physically and mentally degenerate. He gives the following
extract from Mons. Morel as a summary of the argument: — u We
have no need ol further proof, to demonst rate the (act that the I
of toxic inebriating substances gives rise in the race, to the same
pernicious effects as result t«» the individual They have invariably
the same character in all latitudes. . . . New maladies are
generated, and old one- take on increased fatality ; the mean duration
of life i- lessened; the viability of new-born children is gradually
Ii i and less t<» be depended on; and disturbance of the moral and
intellectual nature becomes at length signalised by the highest rates
of insanity, <>i suicide, and crime.11
Should those, commonly termed innann drunkard.-, be committed
i ■ \ -I j.. i'. Lf, iiit Edition.
R ' ' \ ees.
to the ma tones? We think not, • their oa illy
ivided for in the existing Lunatic asylums of the country; in feet,
if such persons were taken from the asylum and placed in the
reformatory, there would be no great occasion for the former, Dr
( irpenter shows that n very large proportion, more than 25 per
cent., of the inmates of lunatic asylums were drunkards, to
nothing of those whose lunacy is one of those " deterioratii.
resulting from having had drunken ancestors. .Mr. Eiaughton
quotes from a cotemporary with reference to this — " Dr. Whitehead
placet intemperate habits first among the causes of insanity in tin-
country, and observes in respect to them — Dr. Cox remarks ' that
nothing is more common than to see the offspring of an intemperate
man become demented.' Dr. Adams also expresses a similar opinion.
I shall, therefore, says the author, offer only one remark on thi-
subject, viz. : — ' that women who are habitual drunkards, generally
produce immature or idiot children.' Lord Shaftesbury says —
* From my own experience as a Commissioner of Lunacy for the
last 20 years, and as Chairman of the Commission during 16 year-.
fortified by inquiries in America, I find that fully six-tenths of all
the cases of insanity to be found in these realms, and in America,
arise from no other cause than habits of intemperance.1 Dr. Cor-
sellis says — ' One-third of the cases in the Wakefield Lunatic
Asylum may be referred to intemperance.' Dr. Whitehead says —
' In an asylum at Liverpool 257 out of 495 patients became insane
through intemperance.' "
Now if we remove from the case those classes already described,
we yet have others so numerous as to require interference. The
confirmed drunkard should be committed, whether he have the
power of self-restraint or not. If in the former predicament, he
can undoubtedly mend ; if in the latter, a great deal may be done
for him which could not possibly be done were he at large.
Every one must admit that the subject of " Chronic Alcoholism"
is a fair case for a reformatory. Mr. Haughton in the pamphlet
already referred to, quotes the following: — " We have made, as it
will be seen, two distinct classes of persons degenerated in conse-
quence of alcoholic excesses. One class arrives at length, by a
series of well marked nervous lesions, physical and intellectual, at
general paralysis. The other, although profoundly affected as
regards innervation, remains stationary at a point, leading a miserable
existence, characterized physically by a special condition of cachexia
and marasmus, morally by a manifestation of the worst tendencies
Reformatories jov Drunkard*. 381
and of the lowest brutishncss." Of the first of these classes (para-
lyzed drunkards) it may he said that they are comparatively harm-
less; but at what cost to themselves and to their families have they
at last arrived at this melancholy state ? The tendency of drinking
to this end cannot be too generally known.
The late Dr. Todd, one of the first physiologists of his day, says,
with reference to the causes of paralysis — " Whatever interferes
materially with the conducting power of nerve fibre, or the gene-
rating power of nerve vesicles (gray matter), will constitute a para-
lysing lesion. Thus, in the first place, poisoning of the nervous
matter will act in this way.a Professor Miller observes — " The
brain, and the nervous system in general, we have seen to be the
parts chiefly acted on in the physiological working of alcohol.5
These cases are more fit for an hospital than for a reformatory, but
not so with the second named class, those affected with the disease
commonly known as " Chronic Alcoholism." Magnus Huss of
Sweden, has lately written a treatise on this subject, but perhaps a
more accessible volume is that on Chronic Alcoholic Intoxication, by
Dr. Marcet, of London, 1860. He says — " The symptoms of the
disease depend on a functional disturbance of the properties of the
nervous system, which may last for weeks, months, or years, even
after the habit of excessive drinking has been given up."c He then
details the cases treated by him with oxide of zinc, and at the end
gives a tabular statement of all particulars. These may be given
shortly as follows: — of 48 cases treated, 24 were cured, 15 ceased
attending, having been relieved or otherwise improved, seven at-
tended only a few times (some once, some twice), one became an
intern patient in the Westminster Hospital, and one is reported as
cured, but continues drinking, and has applied again.
We affirm then, that cases such as these are fit subjects for
committal to the proposed reformatory. That this " Chronic
Alcoholism" is really a bodily disease, and so capable of medical
treatment, we see from the fact that 24 out of the 48 cases were so
cured of it. Further, 15 ceased attending, having improved or been
relieved. Now if these had been in an institution from which they
could not have escaped, they would, in all probability, have been
added to the 24 cures. Seven attended only a few times ; this only
shows that treatment uncombined, with moral and physical restraint,
* Clinical Lectures. 2nd Edition. 1861. p. 609.
b Alcohol, its Place and Power, p. 74.
0 P. 6. Op. Cit.
/,' B bliographie
is bop and the Inst item, one reported " oared, but oontini
in tlu- whole principle of the proposed reform
for in Midi an institution he should not In- discharged immediately
on cure; he should an probation, or get free only con-
ditionally.
The last class of confirmed drunkards which we shall consul
are those afHioted with dipsomania, or, as it hat been more properly
termed, oinomania. These are persons who should be admitted to
our present Lunatic asylums, tor the best of reasons, e they •
lunatics. But even by many who deny their lunacy it will he
admitted, that Borne restraint, in a reformatory tor instance, 11
desirable, although there are those who deem even this - ion
an attempt to interfere with the Libert) of the Bubject.
A Pew words will suffice to describe the oinomaniac: — He I
an irresistable propensity to swallow stimulating drink of any kind,
whenever and wherever he can get it (we have known several
instances where persons having access to drugs of which the con-
veying media were wine, brandy, or spirits, used every means to
take the most nauseous drinks, simply for the stimulating properties
of them); he dislikes society, and drinks, if possible, in secret; nor
can it he said that he drinks tor drinking's sake; it is to free him-
self from the fearful misery occasioned by the non-gratification of
this impulse; he knows he does wrong, and bitterly regrets it, hut
has not the slightest control over the will; he is regardless of health,
life, property, and every other consideration; will sacrifice the
dearest interests of his best friends, and in some cases display a pro-
pensity to commit suicide or homicide. A more full description of
this malady may be found in Dr. Carpenter's welbknown book
already referred to. lie quotes at length from Dr. lluteheson. of
Glasgow, to show that it appears in three forms: the acute, arising
in the course of certain diseases, and disappearing with their cure;
the periodic, or recurring paroxysmal form, arising mainly from
intemperance, sometimes from hereditary transmission, and occa-
sionally from certain diseases — its principal feature being, that
between the attacks the subject becomes quite well, and apparently
cured; and, lastly, the most common or chronic form, wherein the
whole lite becomes one constant scene of miserable degradation.
That a wretch of this kind is a lunatic wc assert.
In the eve of the law a lunatic is one who knows not right from
wrong, and who is therefore an irresponsible person. The main
character of insanity, in a legal point of view, is the existence of
Reformatories for Drunkard
delusion," and hence the law hesitates to recognise any insanity but
flint of the intellectual powers. "There may, however,* be do pri-
mary disorder of the intellectual faculties, and the insanity may
entially consisl in a tendency to disordered emotion — as excite-
ment, which affects the course of thought, and consequently of
action, without disordering the reasoning processes in any other way
than by supplying wrong materials for them. This is now termed
1 MORAL Insanity ;' and in it the subject is moved by a powerful
impulse, amounting to necessity, volition being at the same time in
complete abeyance, and he perfectly aware that he both does wrong
and is amenable to punishment." Another authority saysc — " There
is much latent, undetected, unrecognised insanity in real life, bringing
with it a long train of deep and incurable miseries. It assumes
many aspects ; occasionally it exhibits itself in the form of intem-
perance, an uncontrollable propensity for stimulants, clearly having
a mental origin, in extreme eccentricity, and in acts of a morbidly-
impulsive character." Dr. Forbes Winslow thinks that Moral
Insanity is mostly accompanied by disease of the intellect. Herein
he is probably correct ; and although the law may hesitate to admit
such a disease to be insanity, it does not always so act ; indeed our
law-making should advance in this respect with the psychological
science of the age.
At the Social Science Congress, held in Glasgow in September,
1860, Mr. A Kirkwood read a paper On the Propriety of Placing
Habitual Drunkards under Restraint, ivith a view to their Reformation.
The scheme he proposed was, that lunacy should be declared to
include habitual drunkenness ; that separate asylums for the recep-
tion of such persons should be licensed by the sheriff; that the
sheriff should have the power to send drunkards to these asylums,
either upon the application of relatives, or upon the certificate of twro
medical men ; that the sheriff should have the power of detaining
them six months, or as much longer, up to the period of two years,
as might be necessary.
At the same Congress Dr. Peddie, of Edinburgh, read a paper
recommending the treatment of dipsomania. " Sheriff Barclay (we
quote from a newspaper report) agreed with Dr. Peddie that dip-
somania is insanity, and gave several cases of it — as, for instance, a
woman who was very clever at sewing, but had a drunken mania
* Taylor's Medical Jurisprudence, p. 77-. 1th Edition.
b Carpenter's Principles of Human Physiology, p. 837. 4th Edition.
c Dr. Forbes Winslow's Lettsomian Lectures on Insanity. London, 1854. p. 38.
Reviews and Bibliographic*
breaking windows ; Another man hs (the sheriff) had ml I
tin i jaol fox stealing ipadet, and n tainly the *kn
roades;' another man .stole six tubs — and this s tainlj ■ ' talc
of tube ' lie thought the plea Of the liberty of the subject RW
false ami unsound argument against confining dipsomaniac
The Rei Dr. Guthrie says,a " The law should regard every man
or woman who can be proved, before a jury or any other pro]
authority, to be, by habit and repute, a drunkard, a Lunatic, and deal
with them accordingly. The prospect of a shaven head, ■ strait
jacket (if needful), the high walls of an asylum, and the society of
the insane, would strike men with salutary terror. Months of
sobriety would, in many instances, so restore the brain and body to
health, that the person would acquire the power of resisting temp-
tation, and come out to drink no more; the slave would acquire
freedom in the house of bondage."
Foremost, among the Scottish medical men who have written and
lectured on this subject, stands Dr. Christison, of Edinburgh. His
lecture on some of the medico-legal relations of the habit of intem-
perance, delivered in 1858, is well worthy of public attention —
particularly as we are told that to the opinions advocated therein he
still adheres. lie says: — "There is, fortunately, no difficulty in
pointing out the kind of restraint which is required. In Scotland
medical men have already established a system of treatment which
is applied to those who consent to submit to it, and which seems to
answer every purpose well; so that all the legislation wanted, is to
render compulsory, at the instance of the nearest relative, Avhat is
at present only voluntary. This system consists of seclusion in
some country district, where intoxicating liquors cannot easily be
had ; and where, under charge of a man of education, liberty is no
further restricted than that each inmate must be at home at meal
times, and at a fixed hour for the night, and that he must submit
to all measures necessary for preventing the surreptitious use of
stimulating liquors."
At the Social Science Congress, held in Dublin in August, 1861,
a paper on uncontrollable drunkenness was read by Dr. Mackesy, of
Waterford. The argument pursued throughout is, that by a defect
in our laws the confirmed drunkard is regarded as a sane person ;
whereas such is not tlie fact ; and, because it is not the fact, that
legislative enactments should be made to secure the restraint of such
characters.
a The City, it Sins and Sorrows, p. 140.
Reformatories /or Drunkards. -'Mo
From the preceding statements we conceive we have established
the psychological feet, that Moral [nsanity La quite as irresponsible
as Intellectual. We Bee in the case of the oinomaniac the prominent
features of Lunacy. Prom the description of the disease already
given, ii will be remembered thai the Bubjecl of it Loses control over
his conduct, and cannol hinder his doing wli.it he know- to he
wrong; thai he is propelled by an irresistible impulse to gratify his
propensity, and Bometimes even to destroy his own life, or that of
others; that he cares nol for his family, his property, or any obstacle
to the gratification of his one desire, but readily sacrifices all. Thus
he answers the description of the lunatics who are confined, to prevent
injury to Life and property of themselves or others; and however
responsible for the course of conduct which may have brought the
disease on him, all responsibility must be certainly held to cease
when under its influence. But if the malady has been induced by
hereditary transmission, or caused by some other disease, it is
manifest that he is not responsible, directly or indirectly. Thus, on
children are visited the sins of their fathers. If, then, lunatics
should be placed in asylums, which we all admit; or, which is
equally to the purpose, if they should be placed under forced
restraint, and if oinomaniacs be in truth lunatics, it follows that
they also should be so treated.
We need not pause to consider the good results to all concerned —
the wholesome terror likely to be struck into incipient drunkards ;
but we would earnestly urge that in no other way can a cure be
effected. Dr. Hutcheson, of Glasgow, never heard of more than
two permanent cures; and Professor Stokes, of our own city, stated
in a lecture, a that he never knew of one.
The proposed committal, however, is not hopeless. A friend com-
municated to us the following case : — " A young man, well educated,
became such an incorrigible drunkard that his health declined, and
he was also mentally and morally unfit for any business or pro-
fession. His moral sense was so entirely extinguished that he
immediately disposed of his clothes, newly bought, retaining
only rags to cover his nakedness; and he would steal any article
within his reach; being all the while entitled to a good property,
which a kind guardian dared not surrender to his keeping. Emi-
gration was tried, but in vain; for, after squandering a sum given
him as a kind of venture, he was extricated from an American work-
house, which he had entered as a pauper. As he persisted in the
a At the Meath Hospital, in 1S54.
VOL. XXXIII., NO. 66, N. 8. I
view* ami Bibliogi
sunn- i luct on hifl return t<> Europe, hie guardian, Beeing but
wing bim — that ii to treat him
itated the facts to a magistrate, with a view to nil committal to
lunatic asylum. That gentleman said, 41 accept your evidence of
melancholy facts, and, considering thu the worst form of mania,
I sign the order of committal with a -ate conscience The governor
of a district asylum, fully aware of the acts of th . admit'
the patient. In a few months he was discharged in rem
health; and so salutary has been the effect of the conviction that
there was a power to treat him in this way, that the young
man has never disgraced himself since, in a period of th:
year- " ( )ur correspondent adds — " Names are withheld for obvious
reasons; hut I pledge myself to the truth of the foregoing state-
ment.' '
Here we see committal and treatment cured the man; while the
salutary terror of being 60 treated, should he again fall into the sad
habit, powerfully deterred him from entering even, on what we may
here term kt the first avenues of ill."
But institutions, in some respects resembling those now proposed,
already exist. In Scotland they may be found — for instance, in
Skye. Dr. Christison gives an account of his visit to an asylum for
inebriates in that island. Here, we are told, the same failing
existed, and few permanent recoveries were made, from the want of
controlling power over the inmates, who soon tired of their discipline
and went away ; indeed they became patients, in the first place, only
at the request of their friends, so that nothing better as a result
could have been expected.
In the United State- t4' America reformatories, or asylums for
drunkards, are rapidly becoming national institutions; but, being
only voluntary, they sadly want the principle of legal restraint. In
one, called the New York State Inebriate Asylum, The London
Weekly Record of the Temperance Movement? tells us, that three
thousand inebriates have applied for admission ; and among the
number are said to be 30 clergymen. In the Journal of the American
Temperance Union* we find a detailed account of this same institu-
tion. The following is an extract from the report: — " Up to the
present datec 3,132 applications have been made to enter the asylum,
many of which arc from the patients themselves. These applications
have come from every state in the Union, and from the Canadas.
Of the number who have applied for admission during the past
• No. 204, p. 98. b No. 3, March, 1860. c February 6, 1860.
Reformatories for Drunkards. 387
vcar, nine* have committed suicide while* labouring Under mania a
potu.
In Holland, confirmed drunkards are pul under Legal restraint;
and if. after fair trial, they prove irreclaimable, they are confined for
life, and are considered dead in law. Dr. Mackesy, in In- paper
already referred to. concluded with propositions embodying his
views as to the mode of instituting and conducting these establish-
ments. We commend them to every one who would consider the
subjecl fairly; but we would especially note propositions 9 and
10. Proposition !> is as follows: — "When a patient shall be sent
to one of these establishments ivithout Jiis consent, there should be a
certificate from two medical men, with a declaration of the nearest
relative, stating the history of the case, which should be submitted
to the magistrates at Petty Sessions, who should be empowered to
inquire into the circumstances privately, if the majority deem it
expedient, and the patient can only be admitted on the order of the
magistrates in Petty Sessions assembled, unless in cases of great
urgency and violence, when a case may be admitted on the order of
one magistrate, provided the violence and urgency of the case is
medically certified ; but such cases should be returned to the next
Petty Sessions of the district, when the committal must be con-
firmed, and a Petty Session order obtained." This is fair to the
patient, fair to the family, and fair to the magistrate, who might
incur a heavy responsibility by making an unjustifiable com-
mittal.
Proposition 10 is that " in all such cases there should be an appeal
to the assistant barrister at Quarter Sessions. This should be
allowed in all cases of lunacy and dipsomania, to save the enor-
mous expense of litigation that frequently occurs."
Dr. Guthrie suggests committal by verdict of a jury. Now,
provided that the equitable Scottish system of a majority of jurors
be adopted, and that one of three verdicts be given, no person could
reasonably object to such a course; for it may justly be objected to
that relic of barbarism, trial by unanimous jury, that this is such a
question as a number of men could not at all times be expected to
be unanimous about; and where a unanimous verdict happened to
be given, the less decided in opinion might sometimes l>e presumed
to have giyen way to the judgment of the rest. Moreover, an
innocent person could be acquitted without stain on his character;
whereas the cautious "no! proven" would prevent him who escaped,
through lack of evidence, from being confounded with the " not
i 2
nd bibliographical Xoti
guilt) person, ad in England and Inland, but raighl !•- in-
duce him, if at all responsible, to consider his vrayi and be wrii
It has been objected to legislating in any way for the restraint of
ifirmed drunkards — that law would prove insu
tandard of what is drunken insanity. This is onlj using the
invalid argument ua particular] ad universale;" for even though
>nal error may occur in fixing the Btandard, yet, as the power
appeal would always exist, do great or permanent grievance could
be complained »>f; besides, any argument of this kind applies equally
to all committal for lunacy ; and no person will contend that becau
there have been, and may be, errors of judgment among magistral
physicians, and others, or cwn gross abuses of the power Lodged in
these panic-, therefore the doors of all lunatic asylums Bhould be
thrown open, and all the mad men and women let go tree about the
country.
It has also been objected that such a late would press unequally )
that the poor man would suffer, while the rich drunkard who might
debase himself at home, would practically he exempt. This \\ e
deny ; indeed the unequal pressure, if any, would he the other
way, for the rich man could do more mischief to his family and his
property than the poor man; and this objection also applies to laws
against vices of every kind.
It is said that it would violate the just rights of man. A man may
perform an act in private which is a sin, hut the same act in public
b a crime. Formerly every village had it- resident idiot or
madman, who was hunted into frenzy by the inhabitants, and
exposed by his relatives to make money by his misery ; formerly
a woman could expose her child in small-pox, to gain the alms of
passers by; now neither of these exhibitions is permitted, and
though the prevention of them was doubtless an infringement o^
that grand liberty of the subject, the right to do as he pleases, yet
we all acknowledge its justice, yea, we demand that it should be
so.
Further, it has been objected that it would cause more miser)/ titan
it would put down. Some may perhaps feel it a disgrace to have
a In the army confirmed drunkards might be advantageously treated as diseased
persons. If the drunken soldier, instead of being repeatedly punished, and his many
repetitions of intoxication inserted in the Defaulter's Book, to be finally made the
basis for a trial by Court Martial — if, instead of being so treated, he was sent into
hospital, the best results would follow. At first the hospital might be filled, and the
cells more empty than usual, but ultimately the occasion for both would materially
diminish.
Reformatories for Drunkards,
their relatives thus dealt with; but no sympathy can be extended
towards such as deem the disgraceful term "drunkard" an epithet
lor pardonable or charitable construction. The injury likely to
arise from unjust committal has already been provided against, and
as to depriving an artizan's family of the means of living, by
imprisoning the artizan himself, we would ask, whal meane does he
provide them with while drinking?
It has been alleged that such an institution as that proposed is
illegal in principle, <\< drunkenness is not a crime unless it disturbs
the public peace; and further, that it should not be a crime any
more than gluttony, which is equally condemned by the law of God.
To this we reply, that if it be not a crime by law it ought to be
made one as soon as possible, and that for the very reason why
gluttony should not, because of the miserable consequences to morals
and society entailed by the one, as distinguished from the other,
which, although a sin, yet, even in this life, brings a chain of fierce
diseases as the fair and legitimate consequence of such rebellion
against the constitution and course of nature.
Moreover, it has been objected that the whole scheme is imprac-
ticable from the want of evidence, that relatives or acquaintances
would scarcely ever inform against the delinquent or lunatic. This
is an untenable objection, for the same applies to ordinary lunatics,
and we know that it is highly practicable (and practised too) in such
cases. Lastly, it has been objected that it would be almost impos-
sible to find when the patient ivas cured. Without any experience
of the good results of such reformatories, we may admit this in
part ; but one direct result of their establishment would be, increased
knowdedixe of the disease and its cure, derived from observation and
experience; besides, the adoption of the ticket of leave system
would not fail to keep up a salutary, moral, and physical discipline
on those who might be discharged on probation.
As we have before remarked, the mode of treatment to be pur-
sued in these reformatories should combine the excellencies of
various agencies already at work, ministration to the mind diseased,
to the body diseased, and to the sinful and reprobate soul, as well
as all preventive and recreative measures to save them from that
great evil — being led into temptation. The description of these
means might fill a large volume; any one of them, particularly the
medical part, would form a professional treatise of considerable
importance.
And here might we say a word to those who wholly repudiate
yjO '>. liographical A
our p tfiti • i of drunl lanity, who I that drunkenn<
not a di wid not to be I rith insanity or epilepi
1 1 >f the rei rite of
drinking? do we not every daj Bee that the Bins of fath in
this Life, visited on their ohildren? that men 1i.l\ »-
(using the term in itspopular Bense) bj the thousand, from tin
cause? and shall we not believe that drunkards who, with th
i open, deliberately continue in the besetting Bin, nay, ultimately
deprive themselves of the power of reformation, are irresponsible
when morally insane, but undoubted!) resp msible for becoming -
Dr. Maokesy suggests that these reformatories \x made
supporting, *o as to avoid their being an expense to the nati
We object to this, because then only those who could pay would
derive any benefit from them; the large class that could not, and
that which would not, would thus be practically excluded. They
should be supported by the nation, and should be for all. Even
were it a question of expense, that is easily answered. We read in
Dr. Guthrie's work, The City, its S md Sorrows, that drunken-
ness is the cause of most crimes;* that it causes the annual loss of
60,000 lives in our population; and that £00,000,000 are spent
annually in the United Kingdom on intoxicating liquors. Dr.
Carpenter shows drunkenness to be the oause of many diseasi
Now, if most crimes be got rid of, much legal expense is thereby
saved to the nation. If 60,000 lives be annually lost, the national
wealth sutlers If many millions annually be spent i>n drink, how
much of that could be saved by seriously diminishing this source <»t'
expenditure. If many diseases be produced by it, what a saving
would its diminution be to families and Poor Law Unions ; and if
its widest and most general result, poverty, be diminished, what a
national saving in poor rates to us all.
Our able statesman, Lord Palmerston, has urged on the working
classes the education of their children, and the keeping of social
homes, as powerful antidotes to the public-house and the prison;
this is well, and saves the public much expense in the long run ;
but how much greater would be the expense saved to the country
by the establishment of reformatories for drunkards, is evident from
the data to which we have already referred.
When we express our view, that Total Abstinence Societies are
not well calculated to overcome this great evil, we do not mean to
discourage these useful institutions ; by no means ; we only say that
ft P. 124.
Hi: a i) on Placenta Previa- 391
they we not capable of general adaptation. We have known able
clergymen who never advocated tin- extreme views t hat alcohol in
any degree is poisonous, thai any partaking of it U Binful, and the
like, yel become, Total Abstainers, because, when they urged the
giving up of the sin on B poor man, they were immediately met by
the reply—" It is all very well for you who have plenty, and can
drink your wine quietly at home; why do you not give it up?1'
Thus they have given up the use of alcohol (which, so far from being
at all times poisonous, is, in certain states of the system, food, and
the only FOOD capable of assimilation), a on the principle of St.
Paul, who would neither eat meat nor drink wine while the world
lasted if it made his weak brother to offend. Reformatories for
young criminals are the heralds of a change in our criminal juris-
prudence from the old system of an eye for an eye, to the christian
one of love to our neighbour. Let us hope that reformatories for
drunkards will inaugurate a new era in our national law-giving, and
so keep pace with the rapid progress of Psychological Science.
Placenta Previa ; its History and Treatment. By William Read,
M.D., &c, &c Philadelphia: J. B. Lippincott and Co. 1861.
8vo, pp. 340.
Tins publication appears as the twenty-third volume of the Library
of Practical Medicine, in connexion with the Massachusetts Medical
Society — one, apparently, of a series of such works produced for
the use of the fellows of that body.
The great characteristic of the medical literature of former days
was originality ; we now live in the age of compilations. Absolute
nescience concerning the pathology and treatment of any important
ill " our flesh is heir to," so far from being an impediment to the
indoctrination of others on the same topic, is, it now appears, a
condition qualifying one for that purpose.
During an extensive course of study, necessary to remove his
own ignorance, the diligent student — in these scribbling times —
excerpts copious extracts, and furnishes them, second-hand, to his
brethren.
* See Dr. Henry Kennedy's paper, The Influence of Food on the Intellect, read
before the Social Science Congress, 1SC1 ; also Dr. Todd's 16th Clinical Lecture, 1861.
It i- presumed t.» be incumbent upon ever] memb
don, now, to write; i i n Km « I It i~ considered ni that the
fessional career should be inaugurated by authorship; oon-
lently, haying no resources of hi- own from which to draw, the
phj be is compelled to encroach upon the accumulations of oth<
The receipt for the production of a book ia imple — requiri
indeed, some labour, but merely of a mechanical nature. It is
follows: — Baying chosen a subject upon which to write, you read
and copy the opinions of as many authors as can be procured who
have already published on the same subject These extracts are
then to be arranged in chronological order, and the bias of your
own mind upon the collection is subsequently to be set down. All
then required is your own name to the title-page, and the work is
accomplished.
It is comforting to find that 10s are not singular in the exerc
of this fashion of publication. The present volume fully attei
that America is not free from the prevailing habit of our island-.
We are not acquainted with the professional standing of the
author, or whether lie be qualified to be considered as an authority
upon the subject on which he treats; but that the book has been
"got up" in the manner we have described above, one example will
Suffice to show; and the chapter we allude to may be taken as a
fair sample of every one in the volume.
The introductory chapter commences with the following axiom: —
•• Among all the causes which make labour difficult and dangerous,
none are so much dreaded as placenta previa." This must be
demonstrated satisfactorily, for the information of the medical gentle-
men who compose the body of fellows of the Massachusetts Medical
Society. The author accordingly proceeds thus with his task: —
" There are none more perilous,"' says Laniotte, " than that in
which the after-birth presents itself before the child." " Hemor-
rhage," Bays Deleurye, " is a fearful occurrence to a woman in
labour" — " Conquest says" — " Maunsell remarks" — kk Denman con-
siders"— " The elder Rigby opens his admirable essays by stating" —
"Dr. Collins says" — "Dr. Jn. Bamsbotham says" — "Duncan
Stewart says" — " Mr J. T. Ingleby remarks" — "Madame La
Chapelle remarks" — "Dr. Ed. Rigby says" — "Mr. Bums re-
marks"— " Dr. James Hamilton says" — " Dr. F. H. Ramsbotham
states" — " Cazeau remarks" — "Dr. F. Churchill remarks" — "As
Negelehas observed" — and as Professor Meigs u has spoken," so say.
remark, and speak all : viz. — unavoidable hemorrhage is a dangerous
Read on Placenta Previa. 393
complication in Labour; and bo, we are Bure, the gentlemen of the
Massachusetts Medical Society may iv-t -ati-lird that, such IB the.
fact. Bui as we are already aware that all our midwifery class-
books have told us this tale, and as our experience afl praetilion
lias taught us more forcibly the fact, the only new matter we can
glean from Dr. Read's introductory chapter is, that he, in tin;
absence of practical experience, and from defect of early education,
required to consult every authority before he could be thoroughly
convinced of it himself — a consolatory reflection for his patients.
Upon looking at the heading of the next chapters, however, we
expected to discover some interesting novelty. The question — " How
is placenta previa produced?" would form a fine subject for an
original essay, and is one which would require a very great amount
of medico-physiological learning and research. Yet here our author
by no means quotes many authorities ; but, after about a page has
been devoted to its consideration, dismisses the subject very simply,
very sensibly, but by no means originally, as follows : —
" If we admit the theory that the ovum may be impregnated by the
male fluid as well after it has left the ovary as while retained within the
unruptured (sic) vesicle, the difficulty of accounting for placenta previa
is, to a great extent, removed. For the vivifying influence of the semen
may not have been communicated to it until just at the time the ovum
was leaving the cavity of the uterus, at the os uteri itself, where, in
consequence of this impulse, it attaches itself, and, as the pregnancy goes
on, developes the phenomena of placenta previa."
This chapter headed " How produced," then suddenly branches
out into a statistical account of the frequency of the complication ;
and we are given all the cases recorded by obstetric statistical
authors (with one exception, to which we shall presently draw atten-
tion), "Dr. M'Clintoc" (sic) included. These amount to the number
of 1,276 out of 1,542,772 deliveries, or once in every 1,200 deliveries.
The concluding paragraph is concerning the diagnosis of placenta
previa. This important consideration is most curtly alluded to,
thus : —
" Diagnosis. — The period of pregnancy at which those symptoms occur
which lead us to anticipate placenta previa is very uncertain. They
may manifest themselves at any time after the third (sic) month; but, as
a general rule, are more frequent during the sixth, seventh, and eighth,
than at an earlier period. When, therefore, attacks of hemorrhage come
on in the latter months of pregnancy, without apparent cause, no time
\l Xuticea.
ihoald be lost i" ascertaining U thie complication is
• Whenever hemorrha let witli, v> m
the last three months ft pregnancy, it Is impossible to be too watchful
our patient; as we know not the moment it may become so prol
greatly to endanger life,' En this opinio] tin: author, "allobsi
writers ; and the importance of an early examination cannot be
over-estimated nor too strongly urged."
And this id the amount of Dr. Read's lore upon the diagnosis of
placenta previa! That is, when heniorrh .wards the
terminal months of gestation, especially, no time should be lost in
artaining if the Hooding be the result of placenta previa! Not
one word as to the manner of arriving at a correct conclusion, fur-
ther than, that an examination should be made ! Surely, when our
author took such pains to inform us that placenta previa was a
dangerous complication, we were justified in expecting he would
have eriven a little more information on its diagnosis than he has
done. On this point, of all others in connexion with his subject,
the author would have had an opportunity of displaying practical
knowledge.
With respect to the physiology of the utero-placental circulation,
Dr. Read favours us with no less than 38 pages of quotations from
Hunter down to the authors of the present period. The special
causes of the hemorrhage in cases of placenta previa occupies 34 pages
of matter similarly compiled — the remainder of the volume being
consumed in the consideration of the treatment of this unfortunate
condition.
And now the statistics commence with a vengeance. To arrive
at a correct view of the treatment of placenta previa our author
proceeds, according to the advice of Hie Apostle Paul, which he
very properly states, " applies as well to medicine as theology,"
viz., " Prove all things, hold fast to that which is good;1' and in
following out this inspired teaching, Dr. Read collects all the cases
of placenta previa he can find the history of on record, and arranges
them into stupendous tables — exhibiting a vast amount of labour
and patience — showing their termination and treatment under
various circumstances.
The first table contains the facts connected with 52 cases where
the placenta was expelled and the child born, by the unaided efforts
of nature.
The second table gives a report of 26 cases of " spontaneous
separation of the placenta with artificial delivery of the child1' — viz.,
Kf.ad on Placenta Previa. - > c * .">
those id which uterine action was sufficiently powerful to throw off
the placenta, bui failed in delivering the child.
Table the third gives 31 instances in which the separation of the
placenta was artificial, and the delivery of the child natural.
The fourth table includes those cases in which both the placenta
and the child were artificially delivered — consisting of 51 examples.
"These four tables comprise all the instances in which the placenta
Was completely detached from the uterus before the birth of the child."
The fifth table displays 123 cases in which the placenta was
partially detached, and the child was subsequently delivered without
assistance. In other words, when a portion of the placenta was
detached to an extent sufficient to admit of the child's delivery.
Table the sixth contains the treatment of 557 cases in which a
portion of the placenta was detached, and the child delivered
artificially.
Table the seventh gives those cases in which the placenta was
perforated, and the child variously delivered.
And table the eighth exhibits those in which the mother died
undelivered.
These elaborate tables are drawn up with a view to the deter-
mination of the relative value of the different methods of treatment ,
They are formed upon the following principle in the first four,
viz. : — The number — by whom reported — age of women — number
of pregnancy — duration of pregnancy — condition at delivery — state
of os uteri — presentation of placenta, i. e., whether partial or com-
plete— presentation of child — amount and description of hemorrhage
before interference with placenta, when the placenta was separated
for example — hemorrhage after that interference — hemorrhage from
first interference to time of delivery — the mode of delivery, and
result to mother and child. The other four tables are somewhat
similarly arranged. When it is considered that our author has thus
tabulated so many as 891 cases in these eight tables, some estimate
may be made of the amount of labour his task must have demanded ;
and an idea may be formed, at the same time, of the trouble necessary
for its perusal. It is to be regretted that partial and complete
placenta previa have been indiscriminately combined in all the
tables. Our space will not admit of any lengthened analysis of these
statistics, so we shall content ourselves by giving the general sum-
mary of our author upon them. He says, from the fact that 670,
or more than two-thirds of the entire number, come under the deno-
mination of partial placenta previa,
I
■■ 1 bat the method proposed bj Professor Simpson will ible in
only i small fraction oi . and that the old practice of turning, and
delivering bj the feet, without disturbing the connexions of the p]
anv more than i^ i | for the purpose, must, after all, be our main
it, ami the method which, in the mat coming under char
will must likely be required.11
From the data of his tables our author arrives at the followi
conclusions: —
11 1st. The danger to the mother in placenta previa inert the
period at which labour comes on approaches full time; a result rather to
be expected from the increased capacity of the uterine vessels M DH
nancy advanced to its termination. It is, therefore, better to terminate
the labour after it has really begun, than to endeavour to conduct the
labour to full time.
" 2nd. The danger to the mother is less when the OS uteri is com-
pletely covered, than when a portion only IS involved in the placental
attachment ; and least of all when the attachment becomes nearly or
quite central with reference to the os, if the contractions are vigorous
enough, that the placenta will be thrown off and expelled into the vagina,
and the hemorrhage be checked.
"3rd. The condition of the mother is a much more important element
in making a prognosis of the case than the amount o^l blood lost. . . .
The condition of the mother, then, should be most carefully watched, and
the appearance of any symptoms indicating debility, or a tendency to
collapse, should be the signal for the adoption of such remedies or such a
course as will the most speedily and safely insure the delivery of the
child. And they should be put into effect without any delay, always
bearing in mind the fact that operations which are perfectly safe to the
mother, when her vital power is comparatively undiminished and unim-
paired, become almost certainly fatal if performed when she has become
exhausted by hemorrhage and suffering.
" In those cases where the pains are vigorous, and show a disposition
to be permanent (the head presenting, the os in good condition, and the
strength not materially impaired), rupturing the membranes, by letting off
the waters, and bringing the child's head down upon the os, will, in most
instances, be enough to check the bleeding, and place the mother in a
safe condition. When, however, a want of tonic power is manifested, or
it is probable that resort must be had to forced delivery, the discharge of
the waters in this way will only increase the difficulty of the operation
and the danger to the mother.
" 5th. The danger to the mother is materially increased by artificial
delivery. But the same statistics which show this result also make it
Kkad on Placenta Previa, 397
evident thai this increased fatality is owing, not so much to the operation
Ifi as to the enfeebled and exhausted conditio]] of the mother at the
time; and that, with a favourable condition on the part of the mother,
there is no more danger in resorting to it in placenta previa than in
ordinary cases of difficull labour.
" 6th. The effect "t" artificial delivery to endanger the Life <>f the mother
in placenta previa being, therefore, almost directly proportionate to the
degree of exhaustion under which she labours, it should be the aim of
the practitioner to perform this operation before such a state is reached.
" 7th. If, from the progress of the case or the conditions of the labour,
a resort t«> artificial delivery must finally be had, it should not be delayed
an instant beyond the time when the dilatation or dilatibility of the os
uteri permits the introduction of the hand into the uterus — the danger to
the mother from forced delivery being directly proportionate to the degree
of exhaustion under which she labours.
" 8th. When, from the rapidly-failing condition of the mother, or the
presence of any cause rendering artificial delivery impossible, a resort to
the foregoing is forbidden, the placenta should be wholly separated from
the uterus, and such remedies made use of as will recruit the strength
of the mother, until reaction having been established, she can be delivered
in whatever way may be deemed best.
" 9th. The tampon may be used advantageously in all those cases where,
with an amount of flooding sufficient to materially affect the constitution
of the mother, the os uteri remains so rigid (sic) that it is impossible to
perform artificial delivery. But while, under these circumstances, it is
important to gain time for the dilatation of the os, and, at the same time,
prevent hemorrhage from too speedily exhausting the mother ; under an
opposite state of things a resort to the tampon, by inducing this tem-
porising policy, will often cause a loss of valuable time, and in this way
make just the difference between a safe and a fatal issue. As the effect
of this application is not only to check the hemorrhage, but also to excite
labour pains and dilate the os uteri, it is totally forbidden in all cases
where either, or both, of these results may not be desired.
" 10th. The effect of ergot being of a two-fold nature, according to the
condition of the system (ecbolic or parturient where the nervous energy
is undiminished, and stimulant when there is a want of this), it should
not he administered when there is a probable necessity of terminating the
labour by an operation, unless at such an interval that the effect of it is
either exhausted, or will not come on until after the operation is finished,
or the condition of the mother is such that it will act merely as a
stimulant.
M 11th. In cases when the exhaustion is excessive, and version is the
only alternative, after the feet have \n-i'n brought down, the body of the
child should be left undelivered until the uterus has been roused to con-
R ' iewa and Bibliographical A U
ui.l a iii in condensation >>i us walls hai r- it
withdrawn m iteadirj <is to prevent the evil consequence! irhich
sometimes follow too sudden delivery."
We have quoted these conclusions of our author
much as they are tlif absolute results of his laborious compilatio]
It i- for our readers to determine, whether they have received any
new light on the subject of the treatment of unavoidable hemorrhaj
It is not our intention to make anv lengthened observations upon
these, our author's, conclusions; hut we cannot close our notice
without alluding to the circumstance ofhis having omitted to mention
the most recent statistics on placenta previa published in this
country. Dr. Collins, and Drs. Hardy and M'Clintock's Reports
of the Dublin Lying-in Hospital only have been produced. Drs.
Sinclair's and Johnston's publication was, we presume, not within
his reach, or he would have brought their statistics lorward also.
We strongly recommend the latter publication to the author's atten-
tion. In it he will see the treatment of placenta previa briefly but
tally set down; ami the result of that treatment also exhibited,
proving" its soundness and showing, that in the Irish school of mid-
wifery there exists no doubt relative to the mode of procedure to
be adopted, under every variety of this complication.
Etudes sur le Catlicterisme Curciliqne et sur Vemploi cVune Nouvelle
Sonde, dans le Catlu'tt'risme Evacuatif. Par Le Docteur J. A.
Gely. Avec 101 figures. Paris: Germer Bailliere, 1861.
4to, pp. 172.
Studies on Curvilinear Catlieterism, and on a New Sound in
Evacuatice Catheterism. By Db. J. A. Gely. With 101
figures. Paris: Germer Bailliere, 1861. 4to, pp. 172.
This rather voluminous work pretends to teach us that our
previous notions on introducing instruments through the male
urethra into the bladder are erroneous, and not in accordance with
anatomy or pathology. After a very long preamble, the author
comes to the point in the last few pages ; he finds that the curve
of the urethra is not regular, but is composed of two curves, which
are arcs of different circles ; the posterior, which includes the mem-
Gelt on Cathetmtm. 399
branous and bulbous portions, la fixed; whereas the anterior 14
flexible, not fixed, and benoe its curve is Liable to alteration. It is
the curve of this posterior portion that we are to take into con-
sideration in giving the requisite bend to the catheter, previous to
its introduction; the anterior portion of the canal, for the reasons
Stated, readily adapts itself to instruments of different shape and
measurement. The curve of this posterior portion, the author
states, corresponds to an arc formed by the sixth part of the
circumference of a circle of ten centimetres diameter (8'9 inches);
and meat stress is laid on passing an instrument, which will not
give to any portion of the canal a direction or curve not natural to
the part. According to Dr. Gely's statement, this is done in using
the ordinary instruments, which are bent to correspond to the curve
of the anterior portion of the canal; this curve is greater than
that of the posterior, so that we have the urethra stretched on
an instrument of greater curve than that of the part itself. If
such an instrument be used, the surgeon will experience difficulty
and the patient inconvenience, owing to the straightening of the
curved canal, and also from the point of the catheter impinging on
the walls of the urethra; whereas, it should, if properly curved,
pass directly in the centre of the passage.
This difficulty is more imaginary than real, as every practical
surgeon, who is in the habit of passing the catheter, knows that no
matter what the curve of the instrument may be, he can manage to
pass it by adopting the usual manoeuvres. Of course we are now
considering the healthy, and not a diseased urethra. Notwithstand-
ing, though the author has discovered this happily constructed instru-
ment, which is to fulfil all these requirements, and to fall into the
bladder merely by its own weight, he yet gives directions as to
depressing the handle of the instrument, and several other ex-
pedients put in practice by every surgeon, when requisite, in using
the old-fashioned instruments, which have served us so long and so
well. This is a tacit acknowledgment, that these newly described
instruments sometimes prove as difficult of management, perhaps,
as often so, as their predecessors.
It is ridiculous to suppose that the same curve will suit all cases,
or any particular class of cases. Every day we have opportunities
of seeing that nature is capricious; there is no such thing as
symmetry in nature; no two individuals are formed exactly alike ;
no two surgeons in Dublin would set about passing a catheter in
identically the same manner, and yet they will all succeed;
liographical A I
bably th»- on may h Iter the curve of
the instrument twice or thrice before h<- accomplishes introdu i
it into the bladdt
The ourve of the newly described catheter u intended to
respond to the ourve of the posterior portion of the ureth
Dr. (). divides his individuals into lour da scording to th
height, and development of tin- organs of generation.
The following are bis measurements: —
No. 1 for persons of low stature; the curve of the instrument
should represent the third of the circumference of a circle of ten
c ratimetres diameter (*.« 3*9 inches
N.». '1 for persons of somewhat larger size; the curve of the
instrument should represent the third of the circumference of a
circle of eleven centimetres diameter (4*3 inches).
No. '"> the most usual size, for individuals of middle stature;
the curve should be the third of a circle of twelve centimetres
diameter (4 7 inches).
No I for persons of large stature; the curve should be the
third of a circle of thirteen centimetres diameter (51 inches).
No8. 1, 3, 4, are the sizes in most request; No. 2 is not required
No. 3 will do in that class; and instead of No. 1, the author
proposes to use No. 3, depriving it of one-tenth of its curve, so
that the instrument required for No. I class, should represent nine-
tenths of the third of the circumference of a circle of twelve
centimetres diameter.
The practical inconvenience of such a method is, that a surgeon
setting about the treatment of a ease where the urethra is diseased,
should be provided with a set of instruments of each class, so that
he would require exactly four times the number of instruments
that at present we deem sufficient.
The work exhibits much labour; it is well put together, and
gives a complete history of " Catheterisme" from the earliest period
of the straight catheter ; it must be considered as a useful addition
to our knowledge of the surgery of the urethra. The author has
made a very extended series of investigations as to the true shape
and course o\' the urethra, and gives figures taken from the very
numerous dissections he has made for this purpose. The method
he pursued is an ingenious one, but perhaps not the best suited to
ascertain the true position of the parts. lie made a section of the
pelvis in the median line, and then took a cast, in plaster of Paris,
of the cut surface ; and from this he prepared his diagram. We
M-Call Anderson on Parasitic Affections of the Skin. 401
incline to think thai if he had first hardened the purls in spirit —
after the method adopted by the l:i i * * Mr. Houston, in making the
beautiful preparations in the Museum of the College ofSurgeom
die results would have been more worthy of reliance. Notwith-
standing this, w(> think these figures demand the careful study of all
practical Burgeons.
On the Parasitic Affections of the Skin By T. M'Call Andekm >n,
M.D., &c. London: Churchill. 1861. 8vo, pp. 152.
The substance of this volume, which appeared from time to time
in the pages of the Medical Times and Gazette, having been
thoroughly revised and corrected, is now, with the addition of
wood-cuts, placed before the profession.
Dr. Anderson, in his introduction, adverts very judiciously to
the prevailing neglect of the study of skin diseases ; and after an
allusion to irrelevant matter, passes on to the classification of the
parasitic affections of the skin, which he conveniently divides into
two heads.
1st. Cutaneous affections due to the presence of a vegetable para-
site. 2nd. Cutaneous affections due to the presence of an animal
parasite.
Under the vegetable parasitic class he places favus, tinea tonsu-
rans, alopecia areata, and pityriasis versicolor, believing each of
these four divisions to be due to the presence of a distinct parasite.
Favus, Dr. Anderson believes due to the presence of the Achorion
Schonleini, and under this genus he includes the species — Scald-
head, honeycomb ringworm, Porrigo favosa, Porrigo Lupinosa, Tinea
vera, Porrigo-phyte, Erbgrind, Teigne faveuse (Alibert). He re-
gards Favus as affording an example of a highly successful mode of
treatment, founded upon a correct knowledge of the nature of the
affections; more particularly as demonstrated by the microscope.
The remainder of the second, and the whole of the third chapter he
devotes to the symptoms and microscopical appearances of the
diseased structures; after describing the modes of extracting the
hair, as recommended by Bazin, and others, he goes on to mention
some of the parasiticide applications he has found most efficacious, of
which he gives bichloride of mercury the preference, two grains of
the bichloride to an ounce of water being sufficiently strong.
VOL. XXXIII., NO. 66, N. 8. K
v the other remedies, he refei ilphur, turbith mine]
And oil of cade; and he goes on to saj —
•• It will be Been that the local is the only treatment capab
ly curing fai us ; but, at the same time, in this, as in .ill local di
the genera] health must be attended to, and any deviation from a natural
Btate corrected when possible."
Again —
•• In the epidermic variety depilation is not bo necessary, the application
i parasiticide Lotion, as a solution of the bichloride of mercury, b€
usually sufficient t<> remove it. When the disease attacks the nails, the
treatment is also simple. It i> necessary to destroy gradually, by means
of a small file, the portions of nail covering the favus matter, and after
arriving at it, the application of a parasiticide is quite sufficient to destroy
the fungous growth.
In chapter V., Dr. Anderson treats of tinea tonsurans (clue to
the presence of the tricophyton), adducing proofs that Herpes cir-
oinatus, Herpes tonsurans, and Sycosis are merely \arieties of the
same disease; he then goefl on to the symptoms, diagnosis, mid prog-
nosis of Herpes circinatus, sycosis, and Herpes tonsurans; and, in
chapter VII., he details the causes and treatment of these three
varieties of tinea tonsurans.
Chapter VIII. is occupied with the symptoms, causes, diagnosis,
and treatment of the alopecia areata, a disease elite to the presence
ofthemicrosporon Audouini; an excellent woodcut of the hair from
a case of this disease, containing spores and tubes of the parasite,
being subjoined.
Of the disease due to the presence of the microsporon furfur, he
adduces the pityriasis versicolor; and, in describing its symptoms,
causes, and proofs of its contagious nature, he remarks as follow: —
"Now, I quite admit, that no one case taken separately is sufficient
evidence of the disease being contagious, but taken in the aggregate, I
think they form positive proof of the contagious nature of the disease. It
is, however, equally certain, that it is not so contagious as some of the
other parasitic affections, else we would not meet with so many instances
of husbands affected with the disease who have not communicated it to
their wives, and vice versa. This leads me to state my belief that it is
necessarv to the development of the parasite, that the constitution of the
person attacked, be favourable to its growth. I believe that the reason
this disease is more feebly contagious than other parasitic affections, is —
ManuaU of Chemistry, by Odlikg and Bowman. 403
thai fewer persona supply a aoii favourable to the germination of the
parasite."
Chapter X. is taken up with considerations of phthiriasie and its
species, pediculus corporis, pediculus capitis, and pediculus pubis,
all due to the presence of pediculi.
In chapters XI., XII., and XIII., he treats of thai too familiar
affection, Bcabies; and after describing the history of (ho discovery
of the insect (acarus scabiei), its habits and appearance, he describes
the symptoms and microscopic appearance of the crusts of the so-
called scabies Norvegica ; and under the heading of treatment, he
details the constituents and mode of application of the pomade or
Hcli no rich, the lotion of Vleminckz of Belgium, and Hebra's mo-
dification of Wilkinson's unguent, concluding with the precaution —
" That it is necessary, -whatever preparation you employ, that it be
rubbed into the skin of the whole body, with the exception of the head,
which is not usually attacked ; for if one impregnated acarus is left
unscathed, the disease will soon be as bad as ever."
We have read this little volume with much pleasure. That it
contains some statements which further investigation only can con-
firm, is very wisely anticipated by the author in his preface ; but,
on the whole, it savours of a desire to found the pathology and
treatment of cutaneous diseases on a true base, and thus contrasts
very favourably with many books which have issued from the press
of late years, on the same subject. The work is illustrated with 21
woodcuts, which, on the whole, are neatly executed.
I. A Manual of Chemistry, Descriptive and Theoretical. By
William Odling, M.B., F.R.S., &c, &c., &c. Part I. 8vo,
pp. 380. London: Longman and Co. 1861.
II. An Introduction to Practical Chemistry, including Analysis.
By JOHN E. Bowman, F.C.S., ccc, &c. Edited by Charles
L. BLOXAM, Professor of Practical Chemistry in Kings College,
London. Fourth Edition. 12mo, pp. 311. London: John
( 1. urchill. L861.
THESE two works arc both intended for the use of students; the
first, which is incomplete, " was undertaken more especially at the
K 2
404 views and Bibliogi
request of Pi Brodie, who wished to bare far t h* bis
olasi al Oxford, a chemical text-book, arranged in accordance with
lii- own method of teaching;*1 it represent! the advanced school of
chemists, not only of Oxford, but of Europe, and may be regard
book of IToung-Chemistry j the other book ia of humbler
pretension, and in its present fourth edition, as in it- first, aims at
leading the student, by the beaten paths of recognised methods, to
a knowledge of recognised truths of chemical science ; or, as Youn
Chemistry would Bay, if she knew Latin, " non quo eundem est, sed
quo itur."
Mr. Odling'a work possesses a value for the accomplished chemist,
who may wish to become acquainted with the nomenclature of
Laurent and Gerhardt, but will be found very confusing to the
student, who will discover, after he has mastered it, that he is
unable to understand the language of other chemists.
In 1860, a congress of chemists met at Carlsruhe, to settle the
controversy that exists as to chemical nomenclature, but separated
without arriving at any conclusion; partly on account of the
confusion of tongues, nearly as great as that of Babel, and partly on
account of the obstinacy of the older chemists. The new nomen-
clature, which Mr. Odling adopts, possesses, unquestionably, some
advantages, but it requires such a thorough remodelling of almost
universal forms of language, that many chemists think it will never
be universally adopted.
There are, really, two questions involved; one, that of the use of
unitary formulas ; and the other, that of the change of the atomic
weights of a large number of the elements. The first of these
questions has been discussed for a long time, and the use of unitary
formulas will ultimately prevail, but the progress of the reform has,
we think, been retarded by its being mixed up with the second
question, which involves practical difficulties of the gravest kind.
Let us illustrate, by an example, the change required by the use
of unitary formulas : according to common ideas, sulphuric acid is
a sulphate of water, and is expressed as such by HO,S03, and
sulphate of potash is expressed by KO,S03.
According to the unitary notation, sulphuric acid is considered
as sulphate of hydrogen, and sulphate of potash as sulphate of
potassium; and both are expressed as H,S04, and K,S04. The
theoretical difference in the two points of view is considerable, but
the change of notation is slight.
In like manner, nitric acid and nitrate of potash, would be written
Manuals o/Chemittry^ by Odlino and Bowman. 405
by the common method, IIO,N( ) , and K( >,N( ).-, ; and l>y the unitary
method II, N(),; and K,NO(i.
It' this were the only question involved, Young-Chemistry would
carry the day, as the theoretical advantage and clearness of the
unitary notation are very great; but, unfortunately, ihe other
question of change of atomic weight intervenes, and as sulphur and
oxygen are involved in it, while nitrogen, hydrogen, and potassium
escape, Young-Chemistry requires us to write, instead of HO,S03,
or II,S04, for sulphuric acid, H2S04, while we write K2S04 for
sulphate of potash; on the other hand, instead of HO,N05, or
H,N06, we must write H,N03, and instead of KO,N05, or K,N06,
we must write K,N03.
By the mixing up of the two questions, the result is produced,
that the majority of the formulae used by the new school of
chemistry are not intelligible to older chemists, without a good deal
of preliminary troublesome consideration, which most men are too
indolent to give.
The inconvenience caused by the change of an atomic weight, in
the case of an important element, may be understood from the case
of mercury : if the chloride of mercury be prescribed, it is necessary
that the apothecary should know what school of chemistry the physi-
cian belongs to, in order that he may avoid the risk of poisoning the
patient. If such be the practical difficulty resulting from the change of
the atomic weight of a single metal, let us imagine the confusion that
must ensue from the change of the weights of the metalloids,
oxygen, sulphur, carbon, and silicon. And to add to the confusion
in the case of the latter, the atomic weight is changed in a manner
different from that employed in the case of the other metalloids.
Of the 57 elements, Mr. Odling changes the equivalent number
of twelve, viz., oxygen, sulphur, selenium, tellurium, carbon, silicon,
titanium, tin, tantalum, glucinum, yttrium, thorium ; and of these
elements, silicon is altered in a manner peculiar to itself, and
glucinum, yttrium, and thorium, are also changed according to a
law of their own.
The advantages of a decimal system of weights and measures are
obvious to every intelligent man, and yet few believe that it will
ever be adopted in England, in consequence of the practical incon-
veniences of the change; and it is well known that the introduction
of the Calculus among English mathematicians was retarded for an
almost incredible period, by our prejudices in favour of Newton's
Fluxions. Now, no chemist of the new school can pretend that the
advanl P the new Dotation and atomic weight all
aparable with those of the reforms just mentioned, one of which
rling hopelessly for a hearing, and the other of which
k place »»nl\ within the memorj of many ruin- men. after a
niggle of more than a hundred years between reason and |
judice.
Independently of its new notation, there i- nothing remarkable
in Mr. Odlins's booh, which contains the usual amount of informa-
tion to l>e found in manuals of chemistry, and, we must add, i
alwavs conveyed in the most interesting or instructive manner.
The fourth edition of Mr. Bowman's book is an excellent guide
to the learner commencing his Laboratory experience, and will be
found a useful aid to the student preparing for an examination in
chemistry. It Bhould be remembered, however, that no such guide
can dispense with the aid iA' a skilled practical teacher, under wh.
guidance the learner can acquire a knowledge of manipulation, in a
few days, which he could never obtain from books.
is Iconographique Des Maladies VSnirienn Par ML A.
Cullerier, Chirurgien de Ilopital du Midi, &c., &c. Paris,
Mequignon Marvis, L861. Parts I., II., III., pp. ISO. Nu-
merous Coloured Drawings on Steel.
Tin-: Buccess of former literary ventures has inspired the above
enterprising firm with energy that might well be imitated by their
comrades in trade of this country. Bernard and Iluette's beautiful
little book on Operative Surgery, and Goitre's on Bandaging, are
pretty well known as examples of the perfection to which illustration
can be carried as a means of instruction, and at what moderate c<
The present work is on the same plan, and we have the pleasure of
acknowledging the receipt of the fust three parts often, which are pro-
mised to complete a volume of TOO pages, with SO plates on steel,
from drawings made by M. Leville, after nature. It is impossible
to speak in too high terms of the mode in which all parties con-
cerned in the publishing of these works have done their part.
Paper and printing are admirable ; and the illustrations could not
possibly be surpassed, for accuracy of delineation, and perfection of
colouring.
The present numbers treat of gonorrhoea, and commence with a
Ci llerieb's Illustrations of Venereal I> 407
Bhorl historical sketch of the disease from the times of Moses,
through Hippocrates and his successors, to the day* oi confusion in
the sixteenth century, when, for the firsl time, i1 became the fashion
io look upon it as an off-shool of syphilis. Passing from its history,
the author deals Buccessiyely with its seat, which, in accorda
with routine rather than feet, he places at firsl invariably in the
fossa oavicularis; then he advances to the causes and nature of
gonorrhoea. Under the latter head we haves frill account of the
views of Hunter, and those who followed him, in classing it with
Byphilis; and of the opposing views oi the " iionideiitistes" of whom
Ricord is the modem exponent. This position he has attained by
following out to demonstration, opinions long since fully taught in
this city, by the late Mr. Hewson and Professor Porter. Poth
these gentlemen in their lectures at the Meath Hospital, and else-
where, demonstrated the existence of urethral chancres as the cause
of apparent syphilization by the gonorrhoeal secretion. Had their
observations been attended to, this vexed question would long since
have been set at rest.
Little now can be said of the symptoms of gonorrhoea, and we
pass on to the treatment, Mr. Cullerier is strongly opposed to the
abortive system, among the supporters of which we find the name
of Carmichael quoted ; nor does he seem to be aware of the value
of very weak astringent lotions in the early stage; in fact, the
routine treatment of copaiva and low diet prevails; and injections
are not allowed to come into play till the inflammatory period has
quite passed by. For this wide-spread neglect of the most valuable
means of cure, the violent abortists are to blame ; and it will take
time and patience to bring people back to the due appreciation of
injections, as the most reliable curative agent we possess in all
Btages of the disease.
The remainder of the first number is taken up with some of the
accidental local complications of gonorrhoea — such as phimosis,
paraphimosis, chordee, &C.; and, however valuable as a treatise for
the student, it contains nothing that we need copy into our pages.
Similar remarks will npply generally to the second and third
numbers, which continue the subject of gonorrhoea as it occurs in
the female as well as in the male. We shall reserve further remarks
until the numbers are complete, when we shall be able to take a
more comprehensive review of the Bubject.
We have no doubt this work will have the large -ale which its
enterprising author and publisher deserve.
408
■sumption, it* Ektrty and Remediable Bi I mil
M i > a London: Walton and Maberly. 1862 Poet 8vo,
pp. 4 17.
The author of this work tells us be hae had lour principal obje
in view in writing it, viz., to take advantage of the growing belief
the day, that there i of plitliisis in which this di
remediable as it is irremediable at a later period; to write a prarti-
eal work in which may be faithfully represented the actual condition
of these Case8, when regarded in the great numbers in which they
have been brought before his observation ; to treat the subject
far as possible on the inductive method, and on the improved phy-
logy and pathology of the day; and to give practical effect to
numerous series of special inquiries which have been made by him
during the preceding seven year.-. In seeking to make the work
practical, he has entered largely into all the questions which relate
to food, exertion, climate, and others constituting hygienics, because
such is in accordance with general feeling at the present time;
because this part of medical knowledge is now being placed on the
sure footing of scientific research; and because it must be through
the conditions of the every day life of the patient that medicinal
and other remedial agents may influence the constitution in so
chronic a disease. For the same reasons he has entered fully into
minute details, as it is upon them that the efficient working of a
general plan essentially depends.
From the days of Hippocrates to those of Lamnec, consumption
was distinguished by its general symptoms almost exclusively, but
Lamnec introduced a new era, in which the state of the lungs took
precedence of that of the general symptoms, and tubercle came to
be regarded as the essence, the mark, and the starting point of the
disease. It cannot be wondered at that this became the almost
universal doctrine. Tubercle was something tangible, to be seen
by every observer, and it came to be regarded as the essential fea-
ture of the disease, the cause of its progress in the lungs, and the
source of injury to the general system; but now, at length, as we
recede from the overpowering influence of Lamnecs great discovery,
broader and juster views are being taken; the state of the constitu-
tion which leads to the deposition of tubercle is attracting attention,
and we begin to see that tubercle is not the cause of consumption,
but only a consequence of the diseased state of the system — not the
essence of the disease, but only one of its results.
Smith on Consumption. 409
It is customary at the present day to mark the progress of
phthisis by reference to the lungs only, and to divide it into three
stages, of which the firsi is limited to the period of deposition of
tubercle, the second includes softening of tubercle and destruction of
tissue, and the third is that period when a cavity exists. To this
classification Dr. Smith objects, and, going back to the teaching of
Laamee and Louis, adopts their division into two stages, — that of
deposition of tubercle and that of destruction, to which he adds a
prior stage, to include " all the conditions existing before any
evidence of the deposition of tubercle is afforded," and it is the
consideration of this first or " pretubercular " stage, its definition,
recognition, and treatment that the present work is chiefly devoted.
The evidences of this stage are found to be associated both with
the general system and the lungs, and to be co-existent as to time
in both ; and while these evidences must be variable in degree, as
the type of health varies between " sanguineo-nervous " and the
"lymphatic" temperaments, their general expression is of asthenia
or lessened vital power. States of the general system common to
other diseases with consumption, but in this latter associated with
other special and local conditions.
The method of investigation pursued has been by examinations,
into the precedent and present conditions, of all the patients
presenting themselves at the Brompton Hospital, and, where
practicable, comparing these with the results obtained by the author
in his elaborate researches into the conditions of the body under
varying influences, of which we gave a full analysis in our last
volume.
It appears that, somewhat contrary to common belief, there was
no one temperament exclusively found in phthisical patients, but
that the two extreme types of sanguineo-nervous and lymphatic are
largely diffused amongst them, the general manifestations varying
somewhat, as we have already remarked, in consequence. The
whole processes concerned in the function of alimentation are
commonly lessened in vigour ; the appetite seldom remains
natural, but is somewhat lessened in respect of food in general, and
of some foods in particular, and is commonly wayward and uncertain,
and there is generally some derangement of the function of
digestion, but this is frequently small, and in such cases is not
important ; the tongue is more or less discoloured, or loaded with a
lmff-coloured coat, presents enlarged and projecting papilla), and is
not unfrequently large and flabby ; there is a sense of oppression
tin E md Bibliographical A
after meals, and tenderness on pressure over the epigastrium at m
periods of the day, and a -our taste in the mouth and flatulent
These conditions are most commonly found with the Lymphatic
temperament, whilst in the Bangirineo-nervous the I retaim
usual size and colour, and remains clean.
The weight ami hulk of the body are almost universally < limi-
nished, a fact indicating numerous conditions of great importance,
but not d rily dependent on a Loss of nitrogenous tissue, or
explained by it. But it appears from Dr. Smith's researches that,
when there i- a diminution in the food taken, when there is a 1
perfect assimilation of food, and when fat is disliked, the store of
fat in the body is Lessened, the elimination of fluid increased, the
nitrogenous parts of the body are less perfectly restored, and the
tone of the tissues is lowered. Dr. Smith has rtained many
very remarkable circumstances with regard to the elimination <»t
fluids; in addition to the well known influences of temperature,
atmospheric pressure, exercise, and the quantity of fluid ingested,
it appears the kind of food taken affects it materially; fat, rle-li
and animal foods preventing the elimination of fluid, and the use
of starchy food favouring it; therefore, so long as an abundance of
fat is supplied from without and duly assimilated, or there is an
of fat in the body, there is a power to withhold the extreme
emission of fluids, hut when a person is losing fat, he not only lo
weight pari passu with the loss of fat, but when the store of fat is
exhausted, he loses weight in a rapidly increasing ratio, from the
more rapid elimination of fluid; so the loss of appetite for fat and
flesh has a far greater influence over the weight of the body, than
the mere loss of weight from the want of these substances would
account for.
In the early stages of phthisis the elimination of fluid by the skin,
(perspiration), is, in the absence of inflammation, in excess, this not
only cools the body injuriously and interferes with the heart's action,
but wastes the body by causing a demand for vital transformation
to supply heat from within ; and, in addition to coldness of the
extremities, it causes depression ami exhaustion of the nervous
power. While it is true that perspirations are most profuse in the
latter stages of the disease, it is a mistake, Dr. Smith says, to think
they are confined to these periods, on the contrary, he says they are
met with, though in a less degree, in a majority of cases in the
early stages.
The muscular power is commonly lessened; the circulation is
Smith on Consumption. Ill
enfeebled and Bomewhal quickened; and respiration is shorter, shal-
lower, feebler, and perhaps quicker. When firs! questioned it
commonly occurs that the patienl is unaware of any shortness of
breathing, bu1 be subsequently admits thai <>n any unusual exertion,
as ascending Btairs, or running, his breath is short. He also fre-
quently finds that this state of the respiration is increased after a
meal, and if he cats heartily, or there be much dyspepsia, there if
marked dyspnea. On carefully Looking at the trout of the exposed
chest, it will commonly be found that the breath motion i- lessened
over the whole thorax, but particularly at the upper part of it ; and.
when the spirometer is used, it is found that the quantity of air,
inspired per minute, is considerably lessened. The feebleness and
shallowness of respiration thus manifested, must be attributed to
weakened muscular power and impaired nervous influence ; and the
increased rate of respiration commonly conjoined with them, is pro-
bably compensatory for the diminished quantity of air taken in at
each inspiration.
Dr. Smith also finds, that the vital capacity of the lungs, as
shown by the quantity of air it is possible to expire after the fullest
possible inspiration, is diminished even when there are no evidences
whatever of the presence of tubercular deposits ; but there are, he
says, so many sources of variation in the results of spirometry that,
until the case presents features which, in the hands of competent
men, render spirometry unnecessary, we can seldom go beyond the
fact of having ascertained the amount of air inspired, and must infer
the cause of the supposed diminution with caution.
As a general observation, it may be stated that, at the early
stage of phthisis, there is only a small or moderate amount of cough-
ing, and what there is, is commonly short, and repeated a few times
at each attack ; it is not usually violent or causing much succussion,
but sometimes it is spasmodic. It is usually excited by going into
cold air, by a chill to the surface, and often by eating ; it is fre-
quently irritable in the early morning, and especially soon after
rising. Dr. Smith makes some novel and interesting remarks on
the mechanism of cough in general, in which, he believes, the
pharynx take- an important part, and the greater part of the cough
of early phthisis he attribute- to hyperesthesia of the pharynx,
The quantity of secretion expectorated is very .-mall, and does not
exceed one quarter or half an ounce in the day. and the chief .-ources
«»fit in this early Btage, are the fauces and pharynx, which are, in
this stage, according to Dr. Smith. the chief sourcesof hemoptysis also.
412 t$ and I raj>hical A
\\ t now proceed to disfluw t lie* condition! which are conn©
with the hums. These are, first, le jened movement* of the ch
be detected hy the eye, by palpation, or by measurement, ai irith
the instrument invented hy Dr. Sibson, or that of Dr. Quain, or
Letter still, hy measuring the quantity of air inspired id, the
vesicular murmur is less strong than occur- in health, both in ordi-
nary and forced inspiration. On the patient inspiring forcibly, the
inspiration sounds are, of course, increased considerably in intensity,
but they are more or less tubular, and the vesicular sound is
much Less intense than occurs with the forced inspiration of health,
there being still the same evidence of feebleness of inspiration ;
this serves to distinguish the feeble respiration of early phthisis
from that of mere debility, where the vesicular sounds and the trajet
the air become normal in deep inspirations; third, as tubercle i-
deposited there is evidence of a localised and isolated obstruction to
the current of air; fourth, dulness, on percussion, is a sign of great
importance, but occurs in very different degrees, and under very
different conditions; in the early stage there is an appreciable
degree of dulness on the clavicles, and, indeed, over the chest in
general, before the deposition of tubercle, but not till after the
diminution in the expansion of the lung has been long continued.
The author offers the following summary of the evidences
furnished by the external examination of the lungs: —
" 1. When there is less breath-motion, less length of inspiration, and
feeble, yet tolerably even, vesicular sounds, both with ordinary and forced
respiration over the whole chest, or particularly at one or both apices,
with or without slight dulness, on gentle percussion, of the clavicles, and
without rales or any sign of bronchitis, we believe that there is the early
or the pretubercular stage of phthisis.
" 2. When there is dulness at least moderately pronounced and localised,
and prolonged expiration, with, but sometimes without, flattening of the
chest at the part affected, and with or without wavy or jerking respira-
tion, and with unevenness of the respiratory sounds at the part affected,
in addition to the signs of the first stage, and still without rales or other
evidences of bronchitis, we consider that tubercle is deposited, and the
disease in that part has passed into the second stage.
" 3. When general bronchitis is also present, the diagnosis from the
examination of the chest is almost impossible, and whilst the progress of
the General symptoms may aid as, a correct opinion can only be formed
after the signs of old bronchitis have disappeared, or the general evidences
of phthisis both in the lungs and system have increased.
" 4. The state of the general system is substantially the same, whether
SMITH on Consmnjdion. 413
before or soon After the first deposition <»i' tnbercle, bat the decree of
variation from health will have increased in the latter frith lapeeof time:
hence, whilst this state must he considered in forming oar diagnosis of
phthisis, it is equally indicative in the two Stages, except perhaps in
degree."
Treatment. — Under this head, Dr. Smith first considers the
indications for treatment, and the best method of fulfilling them,
and then gives, in an empirical and categorical manner, a detailed
statement of the whole plan he recommends. The first indication
he holds to be to restore the bulk of the body by lessening elimi-
nation; for this he recommends, 1st. The inunction of oils and fats;
lard, with the addition of a small portion of mutton suet, which
renders it less liable to be rubbed off, being one of the best applica-
tions ; spermaceti ointment, also, is very good ; olive oil is, from its
freedom from smell, least objected to by the patient, but has not
sufficient viscidity ; cod liver oil is objectionable because of its odour.
2nd. The application of cold water, which, by removing the atonic
or relaxed state of the skin, always associated with an unusual
tendency to perspiration, is, if effected with rapidity, very efficacious ;
but it must be applied so that tone may be restored without lower-
ing the temperature of the body. 3rd. Clothing must be carefully
attended to, so much being worn as will allow the skin to be cool,
without the patient experiencing a cold sensation, and where the
extremities are cold, it is essential that their covering should be
abundant. 4th. Regulated but free exposure to the ordinary
variations of the atmosphere is to be commended. 5th. Certain
foods lessen the action of the skin, such as some of the forms of
alcohol, coffee, fats and milk, and are consequently especially fitted
for employment. The old and well-approved combination of rum
and milk, or brandy and milk, in the proportions of two teaspoonfuls
or a desert spoonful of spirit to half a pint of milk, is very proper,
and especially in the early morning, when the skin is commonly
very active. During the day no form is better than home-brewed
ale, or, failing that, Dublin stout ; but the dose should never be so
great as to affect the head, nor should it be continued after the
effect on the skin has been produced ; and in the night hours, when
perspirations are most frequent, food of almost any kind will lessen
them. As for medicines, the well-known remedies, iron, zinc, lead,
acids and vegetable bitters, lessen the action of the skin, sometimes
also, valerian; and when the perspiration has an acid odour, alkalies
are serviceable. All influences likely to increase elimination by the
hi
kidneys and bowels, are to be avoid* l §uch m drinking bu
quantities of water and other fluids, gin and purgntii
The second indication is to restore the bulk of the body, by
increasing the supply. There is very generally ■ deficiency of
nitrogen in adolescence, in consequence of the diminution in the
Bupply of milk, without a corresponding increase of nitrogenous
foods. The proportion of nitrogen in bread is 1 in 22 ; but in
milk it is I in 11, so that for every pound of milk omitted, th
Bhould be two of bread added; and it would require .">.', oun
>d, uncooked fat and Lean meat, to Bupply as much nitrogen as
found in one pint of good new milk. In order that a large quantity
of food may be taken, it is necessary to distribute it well over the
twenty-four horns, and when the patient is unable to take sufficient
food to Bupply the necessary quantity of nitrogen, Bouchards
preparations of glutenized foods may be recommended, these are
gluten bread, which may be toasted and eaten hot ; semola, the
ground gluten bread, containing 80 per cent, of gluten, and
chocolate, the best quality of which contains 10 per cent, of gluten.
Aja the vital actions arc greatly reduced during the night, it
important to supply food then as well as in the day, and the follow-
ing is recommended by Dr. Smith as a scheme of daily diet: —
" 1. Immediately on awaking in the early morning, \ a pint of milk
(hot if possible), alone, or with chocolate added, with bread and butter.
"2. For breakfast : | pint of milk, with coffee, chocolate, or oatmeal,
and eggs or bacon in addition.
"3. At 11 a.m. ^ a pint of milk, or of good beef tea, made from ox
heads or >hins, with bread and butter.
■■ I. An early dinner, with plenty of meat, and milk and egg pudding.
" o. An early tea, consisting of milk with coffee or chocolate, and
bread and butter.
" G. An early supper of J [tint of milk with oatmeal or chocolate, and
bread and butter; or two eggs with bread and butter, and milk to drink.
" 7. During the night a cup of milk and a little bread and butter to be
placed by the bed side and to be eaten if the patient shonld awake.
"By this mode a much larger quantity of food may be taken than
would be possible if the food were given only at the usual meal hours,
and as it will be taken in small quantities, the system will not be
oppressed by it, and the vital actions will not be allowed to subside. It
is a dietary which allows a considerable quantity of nutritious material,
both nitrogenous and hydro-carbonaceous, to be stored up in the system,
since it is rich in both classes of nutriment."
Sm i in on ( onswnption. 1 1 .">
The third indication Lb (<> inorease the vital actions, especially by
stimulating the appetite and the assimilation of food, and improving
digestion, by proper exercise and l>\ regulating the kind of food
used ; for, a> Dr. Smith show-, some Bubstances are not only easily
assimilated, hut aid in the transformation of other foods. Under
this head \)w Smith includes means for increasing innervation and
all tin1 vital functions; but we must close our notice of this very
valuable practical work with extracting the following remarks on
promoting the expansion of the lungs, a prime object in the treat
nient of this stage of consumption : —
" The production of this complete expansion of the chest is oftentimes
a circumstance of extreme difficulty, and sometimes it cannot be effected ;
but the difficulty lies not in any impediment to the entrance of the air,
but in the defect of muscular power to expand the chest, or in the
impossibility of inducing the patient to comprehend the method by which
it is to be effected : hence, however great the difficulty, it lessens by
practice, if the practice be carefully and intelligently made.
" The plan which we adopt is as follows :
" The patient is placed in a sitting or standing posture, with the trunk
erect, the shoulders drawn downward and backward, and the chest
thrown forwards. The mouth is then kept a little open, and the patient
is directed to inhale gently whilst he very evenly expands the chest to
its utmost limits ; and at the end of the inspiration he is directed
to make increased effort, and then to retain the chest in its expanded
state for two or three seconds before expiration is commenced. If the
mouth be shut, the nostrils cannot admit the volume of air with sufficient
freedom ; and if, instead of an even and somewhat gentle inspiration, the
air is drawn in quickly and forcibly, like suddenly snatching asunder the
handles of a pair of bellows, it is impossible for the lungs to become
perfectly expanded. If, at the end of the inspiration, there be not
increased effort made, the mechanical act of distension is materially
lessened, and the good which is effected is imperfect; whilst there is a
manifest advantage in keeping the lungs fully expanded for a few
moments, and afterwards in preventing a collapse of the chest by a
sudden and rapid expiration. The posturing of the chest is also impor-
tant, not only by inducing tliat position in which the cavity may be most
plctelv enlarged, but, by placing the relaxed and elongated pectoral
mnsclefl Upon the Btretch, and holding the shoulders firmly backward, the
greatest amount of muscular power maybe obtained.
"There are two <»i" these conditions which it i- very difficult to fulfil,
viz., tic prevent] f a rapid and gasping inspiration, and the final
effort at the end of inspiration to effect the complete distension of the
416 views and Bibliographical Notic
tangs* Tht former i-> more oommoo ii rpiration i-*
.-hort, And the person is nervous and defective in losrtincn oi ap]
bension, and in inch ohm ii very difficult <>f attainment; whilst tin?
latter is ohiefly associated with much atonicit y of the muscular system,
and in the most intelligent and painstaking person ii only perfect si
long practice. Its increase is, however, a good measure of the unproi
ment of the patient.
"On deep inspiration we find that the apex of the lung is not filled
until the \erv eiul of inspiration, and we have explained this at page 2<
by the common direction of the Bronchi, which carries the current
downwards, and also by the great extent and direction of motion of the
lower ribs, SO that whilst in inspiration the air is admitted into all
permeable parts of the lung, the lower part is first filled by voluntary
effort, and then the upper : hence, for various reasons, we see the im-
portance of the effort to inspire at the very end of the act of inspiration,
with a view to cause the complete expansion of the apices of the lungs.
•• We have found it always necessary to have the chest uncovered, and
to watch carefully the movements of the parts during this procedure, so
as to appreciate any defect in the performance; and moreover, it is
commonly needful that the physician should show the action upon himself.
It is needless to state that it is an easy process to those who can do it ;
but as its entire value rests upon the degree of perfection with which it
can be effected, it demands that the physician be enabled from time to
time to inspect the movements and correct their defect."
PART 111.
MEDICAL MISCELLANY.
Reports, Retrospects, and Scientific Intelligence.
RETROSPECT
OF THE PROGRESS OF SURGERY DURING THE LAST DECADE
BY
MAURICE HENRY COLLIS, M.B., F.R.C.S.L,
Surgeon to the Meath Hospital and County Dublin Infirmary; Member
of Council R.C.S.I., and of Council of Surgical Society.
(Continued from page 192.)
GENITO URINARY ORGANS.
TJie operation for Phimosis needs some comment. In Mr. Erichsen's
Surgery, we have an emphatic condemnation of slitting up the prepuce
for the congenital form of this affection, and a description of circum-
cision, in which, after cutting off the foreskin and slitting up the mucous
covering of the glans, it is directed to trim off the angles and to snip
across thefrenum. Against this last direction an equally emphatic protest
must be entered. Any meddling with the frenum is not only unnecessary
but unjustifiable. It is the most sensitive part of the organ, and a
wound of it La exquisitely painful and remarkably slow to heal: any
curtailing of the folds of mucous membrane, which spring from it, will
leave a cicatrix that will be more or less tight. Very troublesome
Constrictions «>t' the glans result from this operation, which partakes very
much of the character of meddlesome surgery. The skill <»t" the prepuce
is nut bo much in excess aa the mucous covering is scanty. An
operation, then, should have for its objeel to borrow from the skin in
order to make up the deficiency of the mucous membrane. This can be
done by drawing back the prepuce as much as possible, and freeing the
VOL. XXXIII., No. 66, N 8. L
n.s y, D
lining men »n of nicks either in the •
upper surface or at each >i<l<- — a Bmall bistoury, or, what if b< I
will do this, and the operation v. ill be trifling and aim
blo< A stitch or two ma) be i ry at tin- an each nick,
to prevent tin* reunion of their raw surfaces, or the same result n
ured i'V keeping tin- prepuce retracted, but at the risk of a temporary
paiaphymosis arisi Che extra skin, which Mr. Brichsen thinka
much in the way, becomes Inverted and supplement! the deficiencies
the mucous membrane.
For phymosis, the result or encomium of ulcers of the prepuce, the
removal of an oblique ring may be required ; bat even in the* ire
shall do well to keep as clear of the frenum as possible.
Stricture of the Urethra — There has been but little added to Hunter's
opinion of the ordinary locality of stricture, viz.: — "Every part of the
urethra is doI equally subject to stricture; tor there appears to be one part
which is more liable to them than the whole of the urethra I
namely, about the bulbous portion. We find them, moreover, SOmetil
on this side of the bull), but very seldom beyond it. I never bsw a stric-
ture in that part of the urethra which passes through the prostate gland."
Mr. Thompson1 divides the urethra into three regions, excluding the
prostatic portion, in which no true stricture has ever been found upon
tern examination. These regions are: — First, from the posterior
boundary of the membranous portion 1 | inches forward; second, the centre
of the spongy portion; third, from the external orifice backwards for 2h
inches. Out of S20 strictures 215 occurred in region one, 51 in region two,
54 in region three. The mosl common point of all was the junction of the
membranous and spongy portion-, next the anterior boundary of region
one; while, between these two points six examples of Stricture are nut
with for one behind the junction. Mr. Smith's statistics corroborate
these. Stricture in the prostate is affirmed by Ricord and Leroy-
d'Etiolles; but the museums of London, Edinburgh, and Paris present no
example of it. Narrowing of the canal by the pressure of enlar
prostate no doubt occur- frequently, but this must be distinguished from
true stricture. In the Museum of the Meath Hospital there is an example
of what is generally, but erroneously, termed bridle stricture, situated in
the prostatic portion. It is one of those small tibrous bands which stretch
across the canal from side to side, and which owe their existence to an
elongation of a morsel of lymph which has been effused on the surface of
the urethra, and has become organised after acquiring an attachment to
the opposite side of the canal ; or, as Mr. Thompson suggests, to the per-
foration of a follicle by an instrument. The true bridle stricture of Sir
Charles Bell is a fold of thickened mucous membrane, of crescentic form,
tt Stricture of the Urethra. Jacksoniau Prize, 1S52.
Progress of Surgery during the last Decade. 419
partially obstructing the urethra by running half way across it, or ob-
liquely; sometimes two <>r three such partial strictures coalesce, making
the floor or Bides of the canal irregular and rough, ami, as it were,
flattened. The other is scarcely a stricture, hut cither a free band of
lymph OT B short false passage.
Perineal Section, — About 10 years ago there was a hot controversy upon
this subject. This has now <lie»l away, mainly owing to B better defini-
tion of term.-, and to a more perfect comprehension of proper principles
of action. We are in a great measure indebted to Mr. Henry Thompson
for this result. Mr. Symc, it will be remembered, contended that such a
thing as impermeable stricture did not exist. By many he was mi-under-
stood as denying the existence of obliterated urethra. His assertion went
no further than to declare, that in every case in which urine could make
its way from the bladder through the urethra, a catheter could be got into
the bladder by time and patience. This statement of Mr. Syme's coin-
cides with Mr. Liston's experience, and is not contradicted by that of
other surgeons. It does not follow, however, that cutting operations may
not be needed for the immediate relief of a distended bladder, or for the
cure of a contractile stricture. The latter is the condition which Mr.
Syme proposed to remedy by " external division." Prior to him the rule
had been that if a stricture were permeable by instruments external
division is contra-indicated. Mr. Syme proposes to reverse the rule,
namely — " permeability is an indispensable pre-requisite to the perform-
ance of external division." He found that many strictures were so
callous, and had such an inveterate tendency to contract, that within a
few hours after dilatation they were as narrow as ever. He proposed to
divide these by an incision, carried from behind the stricture forwards
to the sound part of the urethra. His narrow grooved staff, with handle
of full size, down to the commencement of the curve, is well known. By a
careful use of this staff the extent of the stricture anteriorly is readily
ascertained, and its complete division secured. A new plastic material
unites the divided surfaces, and is capable of being stretched by the use
of bougies so as to make future contraction of great rarity.
Other surgeons, prior to Mr. Syme, had divided strictures by cutting
down upon the point of a staff passed as far as the stricture, and then
cutting through it backwards towards the bladder, cither with no further
guide, or by the assistance of small grooved directors insinuated through
the stricture from the wound. To this operation the name of " perineal
section" is limited. To Mr. Syme we are indebted for the operation of
"external division," by which the urethra is opened behind the stricture,
upon a grooved staff, ami the stricture divided by a cut forwards along
the raphe. Mr. Bryant, in his Clinical Surgery, gives a very good resume
of the subject from a practical point of view ; but, as is usual with him,
with no reference to authorities. Few years pass by without some surgeon
L2
/'/
Mii-iu for dividing Btricture bv
itroduced into the nrethi eternal division of
cture has never had much favour in this country, and the instru
with the exception of Stafford almost tten or unknown. A
b dangerous mode <>t treatment can scarcely be conceived; and il
a.- matter of surprise to find M. Nelaton state that in more than half the
number of incisions performed in Paris there is hemorrhage, and often to
an alarming amount. Dr. James Axnott* states, that internal inciai
has often proved fatal from hemorrhage, infiltration of urine, and pyemia.
He has also forcibly pointed out the impossibility of limiting tin- incision
to the stricture, if it be made by an instrument which is either push
backwards or drawn forwards; and he has Btriven to obviate all tli
dangers and difficulties by an instrument which shall cut by dir
pressure upon the previously measured Btricture.
The Splitting of Unyielding Strictures, by a dilator, has been largely prac-
tised by Mr. Holt, of Westminster Hospital, and apparently with great
-Lice
The infiltration of urine and abscess which would naturally be sup-
posed to follow from BUCh a proceeding do not do BO; and this is the
more extraordinary as it is generally tin- floor of the urethra that gr
way. This plan of treatment is on its trial. The instrument consists of
the bivalve Staff invented by Perreve, of Paris, with rods of various
M/es, which are run down between the blades, so that the stricture is
suddenly distended by an irresistible force, and is ruptured accordingly.
It" the operation be successful it has the merit of being rapidly so; and
the cure is said to be permanent. Mr. Holt also uses this instrument for
dilating strictures in the ordinary and more gradual manner, which is
in general acceptance with surgeons. Its principle of action in this mode
of application is identical with Mr. Hutton's railroad catheter, and Mr.
Wakley's modification of the same.
Mr. Heath, c^ the West London Hospital, has corroborated Mr. Holt's
treatment in a paper in the Lancet.*
f/i Lithotomy — various improvements have been effected. First, in the
mode of securing the patient. If the chloroform is to be used, the old
plan of fastening the hands to the feet must be given up, as the chest is
thereby dangerously compressed, and respiration impeded. Though no
death may hitherto have taken place from neglect or ignorance of this
matter, yet it is so very easy to understand that such might occur that it
is necessary to draw attention here to the point, though so very self-
evident. In the operation we find Buchanan using a rectangular staff,
and making his incision in the outer parts in a rectangular form, while
the internal incision turns out to be identical with that of the ordinary
tt Medical Times and Gazette, February, 1S61.
b Lancet, August 31, 1861.
Progress of Surgery during the last D ade. 121
incision into the bladder and prostate in the lateral operation. AUarton*
evived the Marian operation (en boutonniere), and has a host of adherents.*1
He pushes the poinl of hi< knife into the central raphe of the perineum,
in Front of the anus, with his Lefl fore-finger in the rectum and the back
of the knife towards the anus; by depressing the curve "I" the staff
towards the rectum, he opens the membranous portion of the urethra, and
then gets a probe into the bladder. The staff is then withdrawn, and the
finger follows the probe into the wound, and the prostatic portion of the
urethra is now gradually dilated to the needful amount. This operation
is essentially the right thing for small stones, and even for thoe
larger Bize it is not unsuitable, as the use of the lithotrite can readily be
combined with it. In children also, whose prostate is small, it is a safer
operation than lateral lithotomy. For the removal of foreign bodies in
the bladder or posterior part of urethra it is also invaluable. I had
occasion to perform such an operation in the year 1853; and from
experiencing its facility and safety, I recommended its adoption for the
extraction of foreign bodies from the bladder. Its applicability for stone
became also evident to me at the same time ; but I did not wish to put it
forward on theoretical grounds ; and, before I had an opportunity of
testing it, Mr. Allarton anticipated me.c The main objection made to
median lithotomy is that it substitutes dilatation and laceration of the
prostate for incision. This, however, is an error. The lateral, or even
bilateral incision of the prostate gives an aperture much too small for
the extraction of an average calculus enclosed in the blades of a forceps;
by the force required to extract it the prostate is more or less lacerated.
No doubt the prostatic tissues are elastic, and yield to some extent, but
not enough to avoid laceration in most cases. Now it is manifest that
the laceration or distension which springs from a central wound in the
gland will be less liable to extend beyond the limits of the gland than
that which springs from a wound reaching almost up to the verge of the
gland. There can be no doubt that most of the deaths in lateral lithotomy
(which amount to 20 per cent, of cases operated on) are due to the
wound extending, either primarily or by subsequent dilatation, beyond
the limits of the capsule of the gland. Besides, it is found that separa-
tion of the fibres of the gland to the necessary amount can be effected
without laceration of the mucous membrane, and that the highly dangerous
infiltration of urine is thereby avoided. Mr. Allarton does not give
chloroform, as the voluntary expulsive power of the bladder is most
useful in the removal of the stone. Many of his patients were up and
* Lithotomy Simplified.
b Teale, of I c. Ward, Lancet, June, I860. Hall, Lancet, September,
]yv'. Hinton, Association Journal, April, 1^."'
c Dr. King, of Hull, Edinburgh Medical Journal. January, 1857. Dublin Quarterly
Journal, Vol. xx.
luring I I '
nt on the da) after the operation ; and be has enjoj
i from mortality, l. . : \ a modification
o! the operation ii suitable. Mr. Lloyd, of St Bartholom< tnd
that no inoonveni* [tending tin- incision into the rectum.
The clean wound of t Ii^ sphincter heals readily by first intention; and
there is no danger of recto- vesial fistula, as in Vacca and Sun i.>-
reaica] operation, inasmuch as the neck of the bladder is not cut.
The following statistics have been furnished t<> me by Mr. Ailarton,
with great kindness, and may i>c relied upon as absolutely correct: —
Total number of cases 154; total deaths L4; avers I in 11.
PaSXICl i akm.d » .w>, OT those in which the age of patient and size
of stone are given.
Age of Patients
No. ot CttM
ittl.S
10 and under,
2
1 il:
11 up to 20,
16
1
1 in 1G
21 up to SO,
10
No.
31 up to 40,
G
No.
1 1 up to 50,
6
2
1 in 3
.") 1 up to GO,
i;;
1
1 in 1:5
01 up to 70,
2G
7
1 in 4
71 and upwards,
G
No.
13
139
Thus leaving 1.") cases not particularised, and 1 death to them.
Of these deaths, one was the case of Mr. Erichsen, at the University
College Hospital, a case which was doomed, no matter what the operation.
Another ease died of diphtheria a considerable time after the operation
(17 days).
Altogether the results are very good, since they are fair average cases,
not done by any one celebrated or successful operator, but by 42 different
operators, many operating for the first time.
There was a controversy, in the year 185G, as to the mode in which Litton
held his knife in cutting for the stone. Mr. Ferguson affirmed that he had
held it underhand, and that the delineations in Miller's, Pirrie's, and
Erichsen's Surgery were erroneous. Mr. Syme took the opposite view,
and showed the danger of plunging into the pelvic viscera a knife with
the fore-finger held on its back. Mr. Erichsen and others took a middle
course, and asserted that Mr. Liston changed the position of the knife
according to circumstances — in the first incision underhand, when striking
the staff overhand. Whether this be correct as regards Mr. Liston may
be a matter of opinion. It may also be a matter of indifference how the
knife is held in the first incision, although it will be more graceful to
Progress of Surgery during tl><' last Decade. L23
hold it underhand; but in striking the staff, it' tl, <»n would avoid
the too common error <>t' striking too far forward, he mnsl hold his knife
as a pen, but with the back of the fingers facing upwards; depressing
his wrist to the utmost, he must, strike upwards (anatomically speaking)
tVoiu the posterior angle of his wound. In executing this manoeuvre the
extensor muscles are put upon an almost painful stretch in order to depress
tin- wrist, and at the same time to elevate the point- of the fingers. To
strike the staff with the knife held underhand is difficult and uncertain ;
the point of the knife will be advanced obliquely if great care be aoi
taken; while with the knife held as a pen, and steadied between the
thumb and first two fingers, with the handle lying between the root of
the thumb and fore-finger, as the feathered end of the pen does in writing,
the natural direction imparted to it in the movement is straightforward,
with a slight upward tendency as regards the operators, and as regards
the patient it is directly towards the membranous portion of the urethra.
If made from the posterior angle of an incision which extends — as
the first incision for lateral lithotomy should do — as far behind the anus
as in front of it. Mr. Erichsen's view, and that of Mr. Syme, approach
theoretical accuracy more nearly than Mr. Ferguson ; but none of the
pictorial representations in the books are to be relied on. None of them
give the position above described ; and in all the fore-finger is much too
far from the point of the knife. No doubt each operator will naturally
hold the knife as is most convenient to himself ; but those who have to
form their hands will find the above method most advantageous.
Some valuable statistics of lithotomy are given from the Norfolk Hospital,3
where for upwards of 80 years a careful record of these cases has been
kept: — Of 863 cases of stone operated on, 755 recovered, 108 died, or 1
in 8. The operations performed were : —
Lateral, 803; Recoveries, 698; Deaths, 105; or 1 in 7*65
Dilatation (females), 41 ,, 39 „ 2 or 1 in 20
Lithotrity, 11 „ 11
Median Lithotomy... 8 „ 7 „ 1 or 1 in 8
All the calculi are preserved and carefully tabulated, to the number of
982, besides 542 presented from various quarters.
For Removal of Stone or Foreign Body from the Bladder of the Female Mr.
Symcb gives a good proceeding. He dilates the urethra, under chloroform,
by a succession of bougies, until the point of the finger reaches the neck of
the bladder, where, feeling the tense resisting fibres situated there, he
makes a very slight incision, hardly more extensive than the blade of a
narrow straight bistoury. The finger is thus enabled to enter the bladder,
and the foreign body can he extracted by forceps, seoop. or hook,
according to its nature. This combination of dilatation and cutting is
a Lancet, September 1, I860.
b Observation! in Clinical Surgery, 1861.
Pro
a judicious improvement on t In use of either alone, inasmuch not
ntinence, the small wound readil) healing, and the
ched but Dot lacerated fibres quickly their tone.
AIi-. Hamilton* gives us a good diagnostic
mark in CASeS of thi^ kind, where, from tin- irritability, pain, ami frequi
calls to make water, the disease might be mistaken for inflammation
the bladder. In both cases the urine may contain much pus, and be turbid,
but in abscess of the prostate the urine is acid, and remains so for
SOme time, while in catarrh of the Madder it IS alkaline, and rapidly
putrifies.
The same writer has more than once drawn attention to the COnnei
ii tubercular disease of the testicle and the " pustnlo-crustaceoai
eruptions" of advanced syphilis.
Cystic Disease of At Fesfw.b— Attention has been drawn to the not in-
frequent confusion of cystic disease of the testis in an advai
with encephaloid cancer of that organ. The particular form of the
disease liable to be confounded with cancer is that in which the CJStS are
filled with a fibrinous material of a brownish-yellow colour, ami pultaceous
consistence. More than half of the specimens labelled as encephaloid of
the testis in the Museum of the Dublin College of Surgeons are of this
comparatively innocent nature; ami the history of such of them as can
be collected from the catalogue and elsewhere corroborates this \ iew.
The structure of the organ seems to favour the development of cysts;
they are undoubtedly formed as a result of inflammatory action in the
tubuli seminiferi which cuts off portions ^( the tubes by adhesion of their
walls, or blocks them up by effusions of blood or lymph. The tubular
structure and high vascularity of the organ makes it subject to the acute
forms of cancer (encephaloid and melanosis), and not to schirrus. Genuine
schirrus of the testis is, as far as my observation goes, an unknown
affection.
Operations for the Cine of Varicocele and Varicose Veins are at present in
great repute in France and England. The simplest and least dangerous
of these are Vidal de Casis', Lee's, Erichsen's, Startin's, Ricord's, and
TufnelTs methods.
Vidal inserts a pin behind the veins, and a wire in front of them, but
through the same apertures in the skin; the wire is passed through holes
in either end of the pin, and the two being twisted, the veins are com-
pressed and gradually cut through.
Lee1' passes two needles under the veins, and applies the twisted suture
for a few days, until the vein is tilled with a coagulum between the sutures ;
he then divides the vein subcutaneously.
!l Dublin Quarterly Journal, May, 1851.
b M. H. Collis, Dublin Quarterly Journal, Vol. xxx.
c Medical Times and Gazette, January, 1853, &c.
Progress of Surgery during the last I haul,. 425
Erichsen* substitutes, for VidaPs bar and wire, a simple loop of wire,
which be gradually twists until it cuts ite way out
Startinb uses whal he terms a bar-needle and clasp, which are con-
venient for many operations besides those on varicose veins. The bar-
needle has a straight shaft and a curved extremity ; the latter enables the
operator to pass it readily under the vein, the former enables it to com-
press the vein when passed through. The clamp is a piece of wire with
a loop at either end, which acts as the thread in the figure of ei;_rhi
sutiu e.
Eticord make- use of two loops of hempen thread which arc passed in
opposite directions — one over and the other under the veins; the ends of
each ligature are then passed through the loop of the other ligature, and
drawn tight.
Mr. Redf ern Davicsc and Mr. Tufnelld substitute wire loops for thread ;
and the latter surgeon adds what he calls " retracting gui These
arc simply threads of wire which are attached to each loop, and which
enable the surgeon to lessen his compression of the vein whenever he
pleases, or to remove the ligature entirely.
Mr. Davies found it impossible to remove the wire ligatures, in one
instance, and was obliged to cut them close off, and leave them in the
man's scrotum, where they appear to have permanently remained without
the patient being incommoded by, or even conscious of, their presence.
All these modifications of metallic ligature are preferable to incision,
excision, or caustic, though none of them are free from danger. In
operations on varicose veins in the leg, it is advisable to place a pad on
the vein above and below the point operated on, so that blood may not
lodge there. There is no greater cause of troublesome and dangerous
pi deb it is than the presence of coagula in the veins. The danger may be
reduced materially by the use of compresses ; but in no case can opera-
tions on veins be considered other than uncertain and dangerous. In
varicocele the use of elastic compresses and suspensories, cold douching
early and late, and abstinence from the general exciting cause will cure
many bad cases, and that with a surprising rapidity. The use of bromide
of potassium (if it can be obtained pure) as an antaphrodisiac, in com-
bination with iron, if necessary, is a useful adjunct; and everything
should be tried before risking the patient's life by operation.
If the mortality were not more than one per cent, we should not be
justified in letting our patient run even that small risk until all other
means had failed. In varicose veins of the leg, the most perfect obliter-
ation will not always cure the ulcers which have called for the operation;
■ British Medical Journal, February, 1860.
: im< I and Gazette, May, 1800.
c Lancet, July, 20, 1861.
d Dublin Quarterly Journal, November, 1861.
/'/ during th,
and it Wt knew hut all, relap-es will hu found to 0CCU1
the ipermtaic reins, do! to speak of the possible atrophy 06 the
which our patient would not thank as. For the leg, a broad band
vulcanised India robber tightly encircling the limb below tl
[amended bv Professor lhuji.i\e, will -oinetiin.
the superficial reins, and drive the blood into the deeper channel*, espe-
cially in thin Subjects, and the plan is unattended with risk, and may
fairly claim a trial.
Fur the Radical Ourtof Hydrocele we have had two >tions which
are not improvements upon Sir Ranald Martin's now well established
treatment. The one by Mr. Lloyd consists in the introduction of a grain
of the red oxide of mercury into the cavity of the tunica vaginalis D]
the point of a probe. Possibly in a case which resists injection of iodine
this severer method might succeed. Cases, however, in which rela;
follows injection of iodine, are very rare, and may generally he cured by
a repetition of the injection. Among many hundred cases which 1 li
seen in various places, 1 have only once known the first injection of iodine
to fail; in this instance BUCC6SS followed on the third trial.
An attempt has been made to revive the old method by seton,a only
substituting ironb or silver" wire for thread; this, however, not only i-
nncertain of success, but has been followed by suppuration and other
mischief.* It should also not be forgotten that infiltration of the cellular
ti->ue of the scrotum (which is apt to occur upon acupuncture, or the
of a seton), is at times a fatal occurrence. For these reasons these
methods cannot be accepted as improvements in the treatment of hydro-
cele. In his Observations in Clinical Surgery Mr. Synie expresses disap-
proval of the wire seton.
ANEURISM.
TJie Treatment of Aneurism by Compression, justly termed the Dublin
method, has attained a settled position in surgery, and needs no special
notice at the present date. The names of llutton, Bellingham, Tufnell,
and Carte in connexion with the origin, the pathology, the literature,
ami the mechanism of this mode of cure, are familiar to us as household
words. Few arteries will now be tied for external aneurism until com-
pression has been found unsuccessful. Even in places where the mosi
unreasoning opposition was given to it, recourse is now had to it, atleasl
occasionally, and once fairly tested it will be sure to find favour. Mr.
Erichsene gives the following statistics as the result of the experience of
London surgeons : —
a Chauliac, 14th century.
b Young and Simpson of Edinburgh. c Erichsen.
d Davidson, of Lincoln.
e Cooper's Surgical Dictionary, 8th Edition.
Progress of Surgery during the last Decade. 127
In compression the failures were u 1 t<> ;">•:;, death* m 1 to L6. In
ligature the failures were as l to 8, the deaths ai 1 to 1 ; this is exclusive
of partial gangrene, secondary hemorrhage, and erysipelas, which fre-
quently resulted from Ligature.
For t he cure of aneurisms which arc not amenable to compression or
ligature, other measures are suggested in the form of galyano-puncture,
injection of perchlorhle of iron, and manipulation. The formation of an
eschar by chloride of zinc paste, applied over the sac, has been BUCCessfu]
in the hands of Bonnet, of Lyons, in a case of subclavian aneurism.
Galvano puncture, first introduced by Mr. Phillips, in 1832, has been
revived by Mr. Bonnet. It is a very painful process, and withal
uncertain, not to say dangerous, though less so than M. Pravas'
injection of perchloride of iron, which is by no means to be considered
in the light of an improvement. There remains the manipulation of the
sac, by which the operator endeavours to loosen some of the softer clots
in the aneurism, in order that they may be driven into the distal portion
of the injured artery, and by blocking up the current, lead to a consoli-
dation of the tumour. This method, due to the inventive genius of Fer-
gusson, is mainly applicable to such tumours as lie at the root of the neck,
and which leave no room for pressure or ligature on the cardiac side.
Mr. Ernest Hart,a surgeon to the "West London Hospital, has ingeniously
combined flexion of the limb with pressure ; this improvement has been
successfully followed by Mr. Shaw,b of the Middlesex Hospital, and by
Mr. Oliver Pemberton,c of Birmingham. The same method has been
adopted for the checking of hemorrhage from wounds of the palmar arch.
The fingers are flexed upon the palm, and the fore-arm upon the arm, and
retained thus by bandages. I have tried flexion in popliteal aneurism,
but without success ; nevertheless I have a high opinion of its value, and
believe it should be added to compression where the latter is not sufficient
alone.
Of Operations for Ligature of Arteries we have a novelty in the late
Professor Porter'sd method for ligature of the common femoral. He
made a transverse incision half an inch below Poupart's ligament of about
four inches long. In thin persons the artery is at once exposed, lying
by itself, and it can be secured quickly and bloodlessly, without fear of
injury to the vein. The objections to this operation, which will naturally
occur, are the injury to the lymphatic vessels, and consequent tendency
to erysipelas, the liability to gangrene from obstruction of so large a
trunk as the common femoral, and the risk of secondary hemorrhage,
a Medico Chirurgical Society, Lancet, May 7, 1859.
b Medico Chirurgical Society, Lancet, May 7, 1859.
e Lancet, September 3, 1859.
d See a paper by his son, Mr. G. H. Porter, in the Dublin Quarterly Journal, Vol.
xxx. ; also Power on the Arteries.
r i
ing to tl e aum en off i proximity to thi
of ligature, li is to i one will prevent thi
ration from meeting with popular acceptance, and prill out-
»h, with most people, the advantages which it undoubtedly po - • i
leaving the rein at a distance, and unmolested by the ligature. I
in which it was lately adopted, the patient died • adary hemorrhs
owing to an accidental high bifurcation of the vessel; the profunda p
off half an inch below Poupai iment, immediately above the
spot where tin- vessel was tied; so that in fact the femoral, and not the
common femoral, was ligatured; in the lower part of the artery there n
a perfect riot ; in the upper, the merest fragment, which might even
due toopost mortem coagulation. The operation however is still sub jud
Some brilliant and daring operations by the old method of cutting into
the Bac and tying the artery at the bleeding point, have been recorded by
Mr. Svme in his Observations in Clinical Surgery. One especially de
notice for a novel expedient which rendered the operation possible, and
which well displays the daring and coolness of that distinguished surgeon.
The tumour was very large, and extended above the clavicle, bo that
ligature of the subclavian became impossible, and amputation at the
shoulder-joint seemed at first the only resource. The rest must be told in
the words of Mr. Syme: — " Before proceeding to this desperate remedy
I felt desirous of ascertaining the state of matters in the axilla, and
therefore proceeded in the following manner: —
"On the 1st of February, chloroform having been administered, I
made an incision along the outer edge of the >terno-niastoid muscle,
through the platysma myoides and fascia of the neck, bo as to allow a
finger to be pushed down to the situation where the subclavian artery
issues from under the scalenus anticus and lies upon the first rib; 1 then
opened the tumour, when a tremendous gush of blood ,-diewed that the
artery was not effectually compressed ; but while I plugged the aperture
with my hand, Mr. Lister who assisted me, by a slight movement of his
finger, which had been thrust deeply under the upper edge of the tumour,
and through the clots contained in it, at length succeeded in getting
command of the vessel. I then laid the cavity freely open, and with
both hands scooped out nearly seven pounds of coagulated blood, as was
ascertained by measurement. The axillary artery appeared to have been
torn across, and as the lower orifice still bled freely, 1 tied it in the first
instance. I next cut through the lesser pectoral muscle, close to the
clavicle, and holding the upper end of the vessel between my linger and
thumb, passed an aneurism needle so as to apply a ligature about half an
inch above the orifice. The extreme elevation of the clavicle, which
rendered the artery so inaccessible from above, of course, facilitated this
procedure from below\"
All went on favourably ; the ligature came away on the thirteenth day;
Progress of Surgery during the last Decade. 129
^i\ weeks after the operation the man was dismissed cured. An equally
daring operation on a gluteal aneurism will be Pound in the same book.
These cases bring to mind an anecdote told of 8 distinguished French
surgeon, which, whether true or aot, exemplifies what may he done by
coolness in the most dangerous emergencies. Having by accident opened
the interna] carotid, when operating in the region of the tonsil, he instantly
checked the alarming arterial hemorrhage by compressing with one hand
the carotid against tin' transverse process of the cervical vertebra, whiL
■with the other he coolly went through the steps of laying bare the vessel,
and when he had accomplished this part of the operation, laying down his
knife and taking up the needle he passed the ligature round the artery,
never letting go his grip of the patient until the vessel was secured, and
the patient's life safe, at least for that turn.
TETANUS.
Professor Haughton has brought forward some cases in which nicotine
appears to have acted as a remedial agent in this formidable affection.
His reasonings were founded on the fact that nicotine is an antidote to
strychnia; and regarding the physiological similarity of the action of
strychnia and of tetanic spasms, he was led to conclude that the antidote
for the former might counteract the latter. Cases in which it has been
tried show that it has a marked control over spasms of the respiratory
muscles. It is to be hoped that this remedy will be fairly tested both
in traumatic and idiopathic tetanus.
INJURIES OF THE HEAD.
The name of Mr. Prescott Hewett may well be associated with this
Bubject, both in consequence of his painstaking course of lectures in the
Medical Times and Gazette, and for his article in Holmes' System of Surgery.
In the latter we have an admirable epitome of the subject, from which the
following extract is made : —
Depressed Fracture. — "The principle of noninterference holds good in
a comminuted fracture, even with depression of the fragments, provided,
tli ere be no wound of the scalp and no symptoms. It is now an established
rule in our metropolitan hospitals that simple fractures of the skull, with
depression and without symptoms, are to be left alone. The depression
may be so marked as to be easily detected; and yet so long as there are
no symptoms all operative interference, of whatsoever kind, is carefully
to be avoided. In such a case recovery may be as rapid and as uninter-
rupted as if there had been no depression of the bone." A caution,
however, Is to be given in such cases to the patient that serious results,
from intra-eranial growths and otherwise, may result from this unrestored
depression. The line of treatment for such fractures, complicated with
wound, i- different ; as Sir A. Cooper and Iirodie have shown, compound
fracture-, with loose or depressed fragments, lead to suppuration; and to
l',< ring the la
prevent the pus from ipreading under the bone its removal ii eall< I for. —
18,
Mr, Hewett's experience ami ree Inst tin'
of concussion of the brain, as ■ eaus< ith, without
of injury in the brain substance. En all inspected oases tin- heart and
spinal chord should be examined as well as the head — the nnt for rap-
ture, tlu- second for extravasation. Man\ of the recorded • Ridden
death from supposed concussion he resolves, by analogy, into one or other
of these. He would also attribute cases in which partial paralysis and
toss of memory occur after injury t<> some extravasation of blood, or to
Some local injury to the brain-substance, rather than to Concussion. This
cannot be looked upon as other than conjectural ; and when we compare
I undoubted concussion with these, we cannot tail to be -truck with
the very gradual manner in which the symptoms coincide and run into
one another; the more BO when we compare cases of what are \ny
graphically styled MENTAL concussion, where the whole train of Bympt
indicative of arrested or depressed action in the brain-substance follow
on a mental shock. In such cases all the immediate symptoms of pro-
found depression, inclusive of irregular or imperfect paralysis of all
voluntary, and many involuntary muscular actions are followed up by
copious phosphatic deposits in the urine, impairment or perversion of the
memory, torpor of the intellectual faculties, &C., in a manner not to be
Confounded with the more local, and possibly more severe, manifestations
of injury due to the presence of a coagulum, or the existence of a rent in
the substance of the brain.
In accordance with the views of Dupuytren and M. Fano, and in
opposition to Sanson and Hornet, he holds, that contusion of the brain has
no symptoms special to itself, ami that its existence may be inferred, but
as yet cannot be proved during life. He thinks that many of the cases
of partial paralysis and failure of memory, after injuries, are due to this
cause, and not to concussion.
Abscess in the Brain. — Dr. Detmolda has, within the last few years,
followed the example of Dupuytren in plunging a knife into the substance
of the brain, in search of pus; his incisions were repeated on three
iasions, and varied in depth from half an inch to one inch and a half,
a probe being passed into the wound, and reaching to the lateral ventricle.
Matter was found on two occasions; but, in spite of this, the man died
after the third incision, seven weeks subsequent to the first, and more
than three months after the compound comminuted fracture which
necessitated the treatment.
FRACTURES.
Starched Bandage. — That muscular action is the chief cause of displace-
ment in fractures of the long bones is admitted as a general rule. The
a American Journal of Medical Science, No. 37.
Progress of Surgery during the last Decade. 431
necessary corollary to this rule is thai efficient control of the muscles
will mainly remedy such displacement. The era of extension and oonnter-
extensioo ss i meani of counteracting, wearying, and paralysing muscular
action, but oof controlling it. seems to be passing away. Men arc now
alive to the impossibility of overcoming the disturbing power of the
muscles by these means, and t<> the mischief of attempting to do so.
There would appear, indeed, to have been always a struggle between
those who used these violent measures ami those who tried simply to le;i\ 6
nature to effect the needful repair, without further interference than was
necessary to ensure perfect repose. But unfortunately, as in many other
branches of medicine and surgery, the dogmas and theories of the schools
prevailed to the exclusion of more simple and rational procedures. From
the time of Hippocrates there have been practitioners in every civilised
community who used their bandages smeared with white of egg and
flour, their plaster moulds, their starch, or gum, or waxed apparatus as
effectually as many of the modern supporters of the appareil immobile.
But these men have been, as a rule, outside the pale of the profession,
and the prejudices of cast prevailed to exclude from due consideration
the principles which their practice involved. Witness the Protest of
Fabricius ab Aquapendente against a slight modification of the method as
proposed by some of his cotemporaries — " Nos autem principes medicinae
sequemur." Although casual mention is made of the immovable apparatus
in the writings of Fabricius, as also in those of Pare', Wiseman, and others,
yet it remained for quite modern times to introduce it into general recogni-
tion as an orthodox means of treatment, and to elicit the principles which
are to guide its application and ensure its success. Belloste, in the last
century, Larrey in the early part of the present, led the way ; and the
latter surgeon stamped it with his approval as the method par excellence
for the treatment of fracture. It is to the late Baron Seutin, of Brussels,
however, that we are mainly indebted for bringing into note the starched
apparatus, and for showing how it may be applied at the earliest stage of
fracture, not only without danger to the limb, but with a certainty of
shortening the period of repair. To Erichsen,a Gamgee,b and others0 is
due the credit of popularising this mode of treatment in these countries.
The old theory of Duhamel and Dupuytren, by which it was supposed
to be necessary that a certain quantity of provisional callus should be thrown
out and ossified as " nature's splint," is shown to be unsound. The most
rapidly and best consolidated fractures are those which have united by the
first intention, without a particle of provisional callus, and the connexion
between inefficient control of muscle and such supcrabundent effusions is
undeniable. In such bones as the tibia, firm bony union between the
* Science and Art of Surgery.
b The Advantage! of the Starched Apparatus.
c On the Union of Fractured Bone. Dublin Quarterly Journal, Vol. xix.
/', the I"
linable in four or even leas, w bei e th< dy
a thin layer of into I lymph to organise and
ensheathing callus i- thrown out, it will \^- at 1- I
this thick and low-organised mass is even imperfect] •!, and
it is more than probable thai the true uniting
does not commence to be ossified in Buch cases until the ensheathing callus
is nearh perfected: hence, in these latter cases, weakness in the limb,
and a tendency to oedema remain for a long time , nl ; and when
the patient bout, there is a certain amount of risk of refracture.
Other and more palpable advantages of the starched apparatus are the
facility with which (he patient can be moved about when the case is dry.
Patients with comminuted fracture of both hones of the leg, for example,
can not only be turned in bed freely, but may get up on crutches on the
third or fourth day after the fracture: hence the muscular system is
kept in tone, and the weakening effects of a prolonged confinement to b
are avoided; in many instances also the patient is able to attend to
business after the first week, if his occupation be of a sedentary nature.
The mode of applying the starched apparatus in general favour i
follows : —
The limb is wrapped in cotton wool so high as the middle of the joint
above the seat of fracture. For example : if the tibia be broken, the wool
must extend half way up the thigh. The layer of wool must be thick,
especially over the seat of fracture, and over tin' joints and bony pro-
minences. Splints or porous pasteboard, well softened, and soaked or
rubbed well with starch, are now placed at each side of the limb, and
behind it, extending as high as the wool. In the example adduced the
lateral splints are furnished with portions for the sides of the foot, while
the posterior splint extends only to the hollow above the heel; in stout
persons an anterior splint may be needed. A roller-bandage, well soaked
in starch, i- now applied evenly over the splints with sufficient tighten -
the splints are graduated in width, BO as to allow an interval of half an
inch at least between their margins. A BOCOnd layer of bandage may be
applied over the first, especially in large people, or in fracture of the
thigh or humerus. Exposure to the air, or the application of hot sand-
bags will dry the case in 24 or oil hour-.
This case should be applied as a rule as early as possible. If applied
before effusion has taken place, it will modify and control it, without the
possibility of exerting injurious pressure. The elasticity of the cotton
admits of unavoidable swelling, and checks what would be excessive, and
this without risk. If effusion has taken place, the same elastic pressure
cheeks its increase, and promotes its absorption. The surgeon has always
a sure criterion that his pressure is not interfering with sufficient circu-
lation if he leave the nails uncovered, and observe the colour and movement
of the blood underneath them. The feelings of the patient are not a
Progress of Surijrrij (luring tlw last Decade. 433
suthcient guide, as it i< well known that gangrene of a limb has occurred
without any complaint of pain being made ; l>ut, if cotton be used in BUffi-
eienl quantities next the akin, strangulation cannot take place. It makes
a difference of at Lead 10 days id the patient's < ralescence if the
apparatus be delayed until effusion arises and subsides; the reparatory
process is interfered with, delayed, and checked by every excess of action
in the part.
This immediate application of the immovable apparatus is the peculiar
feature and great improvement of modern practice. Those who object
to it are those who have seen mischief arise from its improper application,
or who have rot been at the pains to understand its principles ; none who
have once tried the method, as it ought to be applied, will, as a rule,
followr any other. When the case is dry, which will be in 24 hours, or
sooner, if hot sand bags are placed round it, it is to be slit up along the
interval between two of the pasteboard splints ; the surgeon can now
examine each side of the limb by turning down the lateral halves of the case
in succession, an assistant keeping the limb by firm and gentle pressure in
contact with that half of the splint which is not at the moment turned
down. Complete inspection of the limb, without any disturbance of the
fracture, is thus obtained. Any irregularities can be redressed by some
extra padding with cotton wool, and, as the limb shrinks in size, the case
is pared to fit it. An external bandage is applied to keep all in place,
and as soon as all traces of effusion have disappeared, this outer layer
may be starched, and the patient allowed to leave his bed. In this way,
in favourable cases, where the apparatus is applied early, a patient may
be able to be up, and out walking on a crutch, with the limb in a sling,
in three days after fracture.
Baron Suetin used dextrine as a readier material than starch; it has the
advantage of drying more rapidly. Plaster of Paris is also used to saturate
porous bandages, and is still more remarkable for rapidly fixing the limb ;
in children, it has a manifest advantage. White of egg and flour make a
very firm mould and light, but in warm weather it is apt to become
offensive. As starch is a universal commodity, it will, perhaps, be the
general favourite, though where choice can be had, it would not be selected
before dextrine or gypsum.
Whether we apply the appareil immobile, or any other form of splint,
our object must be to control the action of all muscles which have either
origin from, or insertion into the fractured bone. This gives us a rule,
pointed out so long ago, at least, as by Pott, namely — that no apparatus
is worth anything which does not control perfectly the articulation above
and below the seat of fracture.
Fractal* of the Fmwr. — Scarcely a year passes by without some inge-
nious surgeon modifying our fracture apparatus, and in general these
alterations apply specially to the treatment of fracture oj the femur. It
VOL. XXXIII., NO 66, N .8 M
/'/ f & , during the last D
>ven it likely to b<- productn ;dl
thai amendation in these mechanical app]
[d Hamilton <>n Fractures and Dislocations, ■ large coll<
will be found, to which may be added l>r. Gib '{(lint,
Winch, jointed Bplint, Dr. Zachariah Johnson's, Dr. B md
Butcher's splints.
The young Burgeon who feels within him the promptii imbition
to add tt> the armamentarium chirurgorum, w ill do wrell to Btudy what it
already contains, before expending his ingenuity in devising splints for
fractured femur. Those who may iin<l it expedient to employ extending
and counter-extending force, will find the accumulators oi great service.
These are thick ropes of vulcanised India rubber, with rings at each
extremity; when put on the stretch they exert a considerable and con-
tinuous force which may be available for the above purpose. Ban
wire splints deserve favourable notice for lightness and cleanlini
Mr. Hamilton has very carefully gone into the evidence in favour of
bony union of simple intra-capsular fracture of the femur, and expiv-
himself against its occurrence. As has been done by Robert Smith before
him, he resolves the supposed cases into mistakes of diagnosis at the time
of injury, into impacted fractures, and into chronic rheumatic arthritis.
Fracture of Patella.— »Le Gros Clarke suggests a >plint with a circular
or oval aperture in the centre, to correspond with the patella. Sanborn*
applies a broad strap of adhesive plaster from the top of the thigh down to
the noddle of the leg, leaving at the knee a free loop ; bandages are rolled
r the entire limb, omitting the knee ; a small tourniquet pad is pla
above the upper fragment, and a turnstick inserted in the loop and twisted
until the fragments come in contact. The only deficiency in the description
of this plan, as given by Hamilton, consists in there being no means
described for preventing the turnstick from untwisting, a- we can scarcely
suppose the adhesiveness of the plaster to Buffice for this purpose; this
mode might be superadded to the starched case; with the latter howei
alone, admirable results may be secured.
Mr, Tufnellb details a most interesting case of fracture of both patella
in the same individual; slipping Avhile going up stairs she fractured one
patella by muscular action, and falling in consequence, she struck the
other against the steps and fractured it also.
Hooks for Fractured Patella, and the Spike for Oblique Fracture of the
Tibia, which owe their origin to the ingenuity of Malgaigne, cannot be
classed among improvements in surgery, and are only mentioned for the
purpose of showing that the complete neglect winch they have sustained
at the hands of British and Irish surgeons has not been from ignorance
of their existence, but from a well-founded dislike to such retrograde
mechanisms.
* Mr. Hamilton, Op. cit. b Dublin Medical Press.
Progress of Surgery during the /"*/ Dumih-. L35
The swinging cradlea of Luke, Salter, and Gibb are real improvements
conducive to the safety and comforl of the patient, and have come into
genera] use in one Form or other.
/v."' • of //.< Radius, — The ingenuity of surgeons seems well n i.uli
exhausted as regards this Fracture; or perhaps the labours of Colics,
Velpeau, K. Smith, and a host of others bave so clearly elicited the
anatomy of the fracture and the principles of its treatment thai there is
less room for perverse ingenuity. Mr. Gordon, of Belfast, has lately put
forward a splint, the merit of which consists ill using a, wooden pad to fill
Up the concavity of the radius which OUghl to exist at the Beat of fracture.
In the last Dumber of this journal a review of this appeared. The method
is an ingenious modification of what is known at the Mcath Hospital as
Crampton's or Smyly's method. It remains to be seen if the substitution
of a wooden for a soft pad is an improvement — if the splint is long
enough to give support to the hand, and prevent displacement. On the
latter point there is at least a suspicion of well-founded misgiving.
For patients of advanced years Nelaton's method by two splints, a
short anterior and long pistol-shaped dorsal splint seems the favourite.
For the majority of cases, one anterior splint, reaching from the elbow to
the flexures of the fingers, and sloped off to correspond with them, is
sufficient, provided the pad at the wrist be made and kept high enough to
act as a fulcrum, and press against the displaced bone at the seat of
fracture. If, for the first 10 days, the elbow be kept immovable, and the
height o ithe pad from time to time renewed as it becomes flattened, com-
plete reduction of the displacement will be obtained and preserved until
union commences. A light, moulded, splint of Spark's leather may then
be applied for a fortnight longer ; after which some motion of the fingers
may be encouraged, and the apparatus gradually removed. This plan
enables the patient to regain fair use of the hand much sooner than
Nelaton's does. In the latter the tendons are much compressed and
matted, and six months generally elapse before pronation and supination
are restored. Good arms can be turned out either way ; but the Cramp-
ton method has the advantage of putting the arm into the position which
is naturally the most easy, whereas Nelaton's is a cramped and unnatural
position.
8 of Fracture. — Mr. Bryanta gives us some painstaking and useful
tables upon compound fracture, deduced from 302 cases treated in Guy's
Hospital during the last twenty years. Some of his results arc as follows :
Compound fr. of thigh, ... 5'G per ct., of which G-4-7 per ct. proved fatal.
leg, 63-9 „ „ 38-3
» arm, 11*5 „ „ 1 1-1 „
„ fore-arm, 18*8 ., „ 12*2 „
Of the whole number 31*7 pel cent, proved fatal.
* Medico-Cbirurgical Transactions, Vol. xliv.
M 2
Pr § during tht
ili. it would appear that in I to
imputation pyemia it twice us fata] ai in those treated irithout amputa-
tion, and that exhaustion i> a more common cause of death. Delirium
tremens and tetanus were causes oi death more frequently in those not
rated on, than in those subjected to amputation.
In compound fracture of the thigh, as may be expected, the deaths
hold a lar centage. The majority demand amputation ; in I
none but uncomminuted fractures in the young and healthy, or tl
\e in which the comminuted fragments can In- at once removed, h
otherwise a chance of recovery, or of a useful limb.
DJSLOCAT*
Much that is new is DOl to he expected in either the etiology or treat-
ment of dislocations. AVe find a determined effort to bring forward
manipulation as a means of reduction, in preference to extension and
counter-extension. The name of Dr. Reid, of New York, is prominently
connected with a method which is briefly comprehended in the following
direction, as applied to dislocation of the hip: — "Flex the leg upon the
thigh; carry the thigh over the sound one, upwards over the pelvis as
high as the umbilicus, then abduct and rotate it." A variety of means
similar to these have been adopted from the earliest days. Even in
Hippocrates a direction is given for cases that resist extension, to bend
the limb at the joint and rotate; and in many writers since his time such
directions are amplified ami enforced. Dr. Markoe, of New York, adopts
a similar method to Dr. Keid's, with the addition of slowly extending the
limb, after it has been flexed and abducted. Mr. Cock and Mr. Birkett,
among others, have followed Colombat's method, in which the patient
stoops over a table, and the operator stands behind him. The principle,
however, is the same in both — namely, to use the shaft of the femur as a
lever, and bo ad upon the muscles which retain its head in its abnormal
position with irresistible force. Much of the modern ease in reduction
of dislocations is, however, due to chloroform.
PLASTIC 8UBGEBY.
Cleft Palate. — The preceding decade witnessed the rise of Messrs. Fer-
gusson and Mason Warren's improvements in operations for cleft palate.
The last 10 years have seen their suggestions carried out, and, per-
haps, in some degree improved. For the division of the muscles which
act upon the soft palate Mr. George Pollock has suggested a knife,
slightly bent upon the flat, and with a double edge ; with this he cuts the
levator palati from before backwards; and although the incision is neces-
sarily rather larger than Mr. Fergusson's, the surgeon has the advantage
of seeing exactly where he is cutting, and runs no appreciable danger of
Wounding the carotid. Mr. Fergusson's rectangular knife has been
Progress of Surgery during the last Decade. 437
altered by making it probe-pointed, so as to avoid the above-mentioned
risk, and bo prevent the poinl from hanging in the muscles of the
pharynx, as it was found liable to do during the spasmodic efforts of the
patienl at deglutition.1
Mr, I*. C. Smyly has suggested and practised the division of the leva-
tor and tensor palati muscles, by means of a small sickle-shaped knife
introduced through the QostriL As soon as the blade u passed back
through th*' posterior nares, the operator turns the cutting edge down-
wards; he then places the tip of the fore finger of the disengaged hand
against the hanmlar process, and drawing the knife forward, severs all the
muscular structures which intervene between his finger and the edge of
the knife; dissection will show that this incision will implicate the leva-
tor and tensor palati muscles.
Mr. L'Estrange, long ago suggested that much assistance could be
obtained, in all stages of the operation, by passing a thread through the
point of the divided uvula at each side, and using it as a forceps to hold
and draw upon the velum, so as to make it tense for the paring knife, or
for the insertion of the sutures. I have borne testimony to the value of
this suggestion, and Mr. Pollock has since adopted it.
In the separation of the muco-fibrous covering from the bony vault
much facility and rapidity of execution can now be attained by intro-
ducing the knife through the nostril, at the earlier steps of the operation,
as suggested by Mr. P. C. Smyly. The length of the operation is
much diminished, as the operator can see what he is about, and
can work with more freedom and certainty. There has been some
correspondence lately between Langenbeck and Mr. Hulkeb on the sub-
ject of a claim which the former makes to priority in detaching the
periosteum along with the mucous coverings of the bony vault. No
doubt whatever Herr Langenbeck makes this claim in good faith ; but
there is also no doubt that Mr. George Pollock, of St. George's
Hospital, detached the muco-fibrous covering of the palate with chisel-
edged knives, in July, 1855. I assisted at the operation — having gone
over to London for the purpose. And in the latter part of the same year
I repeated the manoeuvre on another patient in the Meath Hospital. Mr.
Pollock and I discussed the question of danger to the bones if deprived
of their periosteum, and we came to the conclusion that the anastomosis of
the vessels through the bones, from the periosteum of one side to that of
the other, was so free in this situation that there was no danger of ex-
foliation; and the result justified the opinion. From the success of
Mason Warren's operations I am inclined to think that he also detached
periosteum along with mucous membrane as early as the year 1843. This,
'See a paper on Cleft Palate, by Mr. If. II. Colfia, Dublin Quarterly Journal,
Vol. xxi., p. -J77.
b Medical Times and Gazette, August and November, 1861.
/'/ during the ' • ' I '
li . \ mise. What I state aboutMr.PoUo
much mechanical ingenuity I led.
tin's tubular needle is the only improvement which need be notii
1 mihi s tv that I personally prefer Liston's needles to any other method
inserting sutures. With three of these differing in curve from fetch
other, any man who chooses to educate his hands, can pass sutures
than with any other mechanical appliance. In fact, there i
difficulty in planting a Buture anywnere within view, and many a one
1 have inserted where 1 could only see the point of entrance.
Vesico-vaginal Fistula, — Upon the kindred Bubject of vaginal fistula
there is good reason for congratulation. The introduction of the Bilver
wire suture by Marion Sims, has enabled us to grapple successfully with
what ^was one of the greatest opprobria of surgical art. It is not necessary
to enumerate the host of ingenious plans which our transatlantic brethren
delight in offering for our adoption. I believe we shall come in time to
find that the majority of cases can be cured by simple vivifying of the
edges, and close stitching with silver sutures, and that Marion Sims1
natal bar-, Bozeman's shield of lead, and other kindred appliances, will
be of exceptional usefulness. I dare say my own favourite quilled suture
of vulcanized India rubber will come into the same category, although it
may seem to deserve a better fate, as having been the mean- of reviving
the belief of our Dublin surgeons in the curability of the accident.
In this branch of plastic surgery, we have no reason, in Dublin, to
feel dissatisfied with the success of the past decade. There have been
many operators, since my filBt case in the year L855, and each
lias contributed his share of SUCC6S8, and has added to our practical
experience of the various modes and positions of operating. Marion
Sims' duck-billed speculum is of great, though not invariable, value. In
some cases broad brass spatula' will answer better, ami in fact, most of
best case8 were done with these. Mr. Ililliard of Glasgow, has
made a quadrilateral dilating speculum, which expands the interior of the
ina to the utmost, and which lias the advantage of being self-retaining.
It is highly spoken of by Dr. J. B. Brown. Dr. Simpson of Edinburgh, has
found iron wire to answer as well as silver, for the sutures. In my hands
it has not done BO, and the general feeling of the profession, both here and
in London, is in favour of the more noble metal.11
Ruptured Perineum, ijr. — Dr. J. 15. Brown, l) of London, has done much to
perfect operations for the cure of ruptured perineum, vaginal cystocele
and rectocele, and prolapse of the uterus. By a suiTieiently extensive
removal of the mucous membrane of the vagina, and by paring the
ruptured edges he obtains a large extent of raw surface, and by the quilled
suture these are kept in close apposition until union takes place ; a free
* Lancet, March, 1858.
b Surgical Diseases of Women.
/'roorrss < w.ry during the hut Decade. L39
division of the Bphincter being added for the purpose of paralysing its
action. The form and extent of the ran e which he makes depend
mi the amount of laceration, and the seal and severity of the prola]
The division of the Bphincter is only necessary for ruptured perineum.
Jn few words, the principle of bis operation consists in obtaining, not so
much a closure of the orifice of the vulva, as a narrowing of the vagina,
and attention to this poinl explains the success, and the superiority of his
proceeding over those of others.
Hare Lip. — Allan Duke, of Chichester, has revived the use of fine
interrupted ligatures on the mucous surface, and there lias been an attempt
to revert t<> the older plan of quilled suture, which was the rule before the
twisted suture was copied from the tailors. The deformity which remains
after the best planned operation for hare lip, consists in the lip being both
too thin, and too shallow at the point of union ; this results from a gradual
thinning of the cicatrix, and can only be obviated by making the lip, if
possible, a little too thick and too deep at the time of operating. This
may be effected by making the incision more curved than it usually is.
The gap corresponds to, what ought to be in most faces, a curved and raised
line; but the ordinary straight incision, by which the edges are vivified,
necessarily leaves a straight cicatrix, and, generally, a depression where an
elevation ought to be. This deformity might be remedied by hollowing
out the edges with a narrow bladed knife, as they are being vivified, and
the lip might be thickened by using the quilled suture.
It is a matter of surprise to find so intelligent an observer as Mr.
Spencer Wells, putting forward, as his opinion, that simple hare lip is
merely non-union of the median labial fissure ;a the situation of the cleft
i- always to one side of the mesial line, and corresponds to one, or both,
of the ridges which run from the nose to the free border of the lip.
A variety of methods have been proposed to increase the depth of the
lip. and prevent the little tuck up, which almost invariably is observed at
the point of the cicatrix. Malgaigne carries his incision down, at each side,
towards, but not through, the free border of the lip, he then cuts off two-
thirds of the little slips and turns down the remaining third of each, so as
to form a projecting nipple along the free border. This can be trimmed
afterwards if too exuberant. Langenbeck and Coste, of Marseilles, pare
one side in the same manner as Malgaigne, and the other they simply pan-,
rounding off the free angle, so as to get a raw surface along the border of
tie- lip, to which to apply the lower third of the slip of the opposite side,
thus making the cicatrix vertical through the upper two-thirds, and
oblique along the lower third of its extent. Sedillot used a similar
manoeuvre to that of Malgaigne, and I remember to have heard Mr.
Smith, of the Leeds Infirmary, describe a similar proceeding as one
which he had been in the habit of following for
a Surgical Dictionary, 8th Edition.
I in Progress of Surgery during thi ' I D
M «t Burgeons will now follow tin- conservatiTC practice of Gensoul,
in irt;tiiuii nitra] bone in OMOi of double hare Up and fissured
arreoH and palate j except in < I extraordinary deformity it mas
pushed back into its place with advantage. Mr. Butcher" hai Agun
bone nippers by which the poceosary partial incisions into its pedicle i
be effected.
In separating the lip from the alveolar ptoeeae, Soupert [Now
proc^de pour le Bee de lie*vre, Brussels, 1858],* is careful to preserve the
labial frenum, as he imagines that in after life the lip loses much of tti
characteristic expression if tlu- frenum be removed. The labial frenum
proper should never be divided, but the adhesion of the outer border of
the fissure to the alveolar mucous membrane should always be divided.
Care should also be taken not to separate the fold of mucous membrane
above its proper line of reflection from the gum to the lip, as a fistulous
opening sometimes remains upwards to the nares, if this be done. Too
extensive severing of these natural reflections of the membrane leads to the
lip becoming too shallow at the very point where increased depth is required.
Some of Mr. Bryant's clinical notes on this subject are interesting. Of
47 cases, 30 occurred in boys, but 17 in girls, thus corroborating the
general notion that the malformatiou is commoner in male than in female
children.
21 were simple hare lip.
3 complicated with fissured gum.
2 ,, „ hard palate.
17 „ Boft do., and
2 were double.
11 were operated on.
3 within a fortnight after birth, of whom one died.
7 were four or five weeks old ; in two of whom the line of union gave
way, but subsequently closed by granulation.
6 were operated on between 6th and 7th week successfully.
10 between 3rd and 6th month, with one failure.
5 „ 6th and 12th, successfully.
13 after 1st year, „
These results are in favour of delaying the operation until about the
sixth month. Earlier operations may succeed even in a majority of caseSj
but one or two failures from premature interference will more than justify
the delay.
Mr. Butcher is in favour of early operation, justly considering that the
success of this, as of many other operations, depends much on the care
and skill of the surgeon, and on the health rather than on the age of the
patient.
* Dublin Quarterly Journal, 29.
b Surgical Dictionary, p. 869, 8th Edition.
Progress of Surgery during the last Decade, 441
Deformities resulting from Burns. — Mr. Etjnd" proposed and executed Em
operation tor the remedy of these deformities, t<> which his iiainr. deserves
to be attached. It Consisted first, in making bis incision beyond the mar-
gin of the injured skin, "m parts thai were perfectly sound; and secondly,
in dissecting op along with the flap every portion of underlying fascia, or
c\ en muscle, which had been included in the original injury and which bad
undergone the contractile change which results from it. To Bynd's opera-
tion Butcherb has added a subcutaneous scoring of the flap and division
of such bands as threw it into ridges. Mr. Barton0 recommends that
simple extension should first be tried, then subcutaneous section of
unyielding bands, and if these were insufficient, the severer operation
of dissecting up the flaps.
TRACHEOTOMY.
For facilitating the opening of the trachea we have various forms of
grooved hook proposed. Spencer Wells suggests the cassigna, or hook
grooved on its convexity, Lawford on the concavity, and Churchill on the
side. Marshall Hall suggested a common sharp pointed pair of scissors
with which, in emergencies, to divide the integument, and by a plunge
to enter the trachea, then by divaricating the blades, to allow the entrance
of air.
In the Journal de Medicine et Chirurgie for March, 1856, we have an
account of 57 cures through tracheotomy, in 264 hopeless cases of croup,
by Guersent. Unfortunately in this country we are not able to produce
anything like so favourable statistics. Whether the disease is different
in type, or that they operate earlier in France, certain it is that the most
successful operators here can produce few, if any, genuine recoveries in
the later stages of croup by the operation of tracheotomy ; and one can
see good reason why it should be so, if the formation of the false mem-
brane be from below upward, and not from above downwards ; so that
the lungs are hopelessly inflamed and blocked up before the trachea is
affected.
Fock also states that he saved 10 cases out of 24 in the last stages of
the diseased
ORTHOrEDIC SURGERY.
In Orthopedic Surgmj we have a reaction against indiscriminate
tenotomy. Mr. Adamse has shown that tendons contained in synovial
* Dublin Quarterly Journal, Vol. xxii.
fc Dublin Quarterly Journal, Vol. xxxiii.
c Dublin Quarterly Journal, Vol. xxxii.
d Deutsche Klinik, 1859.
• Adams on the Reparative Process in Human Tendons.
1 u Pi 1 >
itbfl do it- * i unite when divided, but that they form adh<
the sides oi the sheath, and that the interval between their
ends rmanent; thus a considerable loss of power result*. 1
statement, as regards human tendons, coincides with the pn
orience oi M. Bouvier on the tendons of animals, and ii
ported bj Mr. Harwell/ win* \x as to say that such mneelet
the tibialis posticus, and flexor longns digitorum, might as weM
struck by sudden and Irremediable paralysis, subjected to the knife
oi the tenotomist ; and that the tibialis anticus is only a little better
circumstanced. Tin- peronei also are similarly Bituated.
1 h , two very simple and efficient forms oi splint for varus,
a straight piece tit flexible tin, covered with chamois leather, an inch and
quarter, or BO, wide, and long enough to wind round the toot and extend
along the outside oi the leg, well above the knee. This acts as an
external ligament or set of muscles, and when secured by a bandage it
can he bent to any required position, which it will retain, and thus
rcise any required amount of force, and in the direction that seems
most suitable to the surgeon. This simple splint was devised by Mr.
Wharton, of the Mcath Hospital, and has been of great service in several
cases in which I have used it. Another very similar idea is embodied in
a straight splint of Mr. Adams,1' which is made of tinned iron, and runs
down the outside of the leg from the knee, below the foot ; it is slightly
hollowed to the shape of the leg, the upper end is firmly bandaged to the
knee and calf, and by this means a lever power is obtained, so that by
Continuing the bandage down the limb, great force can be brought to bear
upon the inverted foot. There is not, however, the same power to bring
down the heel which can be exercised by Mr. Wharton's splint, or by
Mr. Colles' simple hoop-iron splint, described in the first number of the
'•'in Hospital Reports, but it is oi great service in the later stage-
cure.
Of strange operations, Mayer's for genu valgum is the strangest; he
cut out a wedge-shaped piece from the inner side of each tibia, below the
tuberosity, and treating his wound as a compound fracture, succeeded in
obtaining for his patient a pair of straight legs! Ce jtu ne raut pas Ut
cha addle. c
MINOR SURGERY, INSTRUMENTS, &C.
Removing Carious Bone. — Among hundreds of implements few sur-
pass the osteotrite of Mr. Marshall, and the double orforceps-tjouge of Coxcter.
The former is an enlarged edition of the common mill-head used by
dentists ; it is most efficient for clearing away all that is diseased in
a Medico-Chirurgical Society Reports, in British Medical Journal, Dec. 7, 1861.
b Medical Times and Gazette, July, 18f>7.
c Heyfelder's Memoirs on Resections.
/'/ of Surgery during flu last Decade* \ !.">
irregular cavities, while the gouge forceps is mosl efficienl in removing
projecting irregularities,
The icraaeur invented by Chassaiguac \\;i-. at first, to supersede all
eutting instruments; and its admirers vrenl so tar a- to invert an o
eUui to enable the surgeon to performs bloodless amputation. Bat this
first enthusiasm lias died away, and it now remains a useful instrument
for the removal of hemorrhoids or any small pedunculated tumours,
especially those arising from mucous surfaces, with a caution againsl too
free removal in the case of piles, as mechanical stricture of the anus has
been the result in some eases.
The drainage tabes of the same author should also be mentioned ,
useful modification of a very old method of treating chronic abscess.
The scrres-jines of Vidal arc not as much used as they might be for
retaining the margins of wounds in contact. Probably the general
introduction of metal sutures, for which we are indebted to Marion Sims,
Simpson, and others, has somewhat superseded their use.
The Acupressure Needles. — With Professor Simpson's we are all tolerably
familiar. They too would seem to have been accorded at first a too
extensive applicability, and to have been used in cases where, to say the
least, they were not wanted. It remains to be seen if they are destined
to take any permanent place in the surgeon's armamentarium.
For paracentesis thoracis, Mr. C. R. Thompson, of Westerham,a has
devised an excellent canula and trochar, by which the entrance of air
into the pleura is rendered impossible. The canula is four inches long ;
near its middle a short silver tube of the same calibre is let in at right
angles ; to this side piece, a foot or so of India rubber tubing is to be
attached, the end of which is to lie in a vessel of water, with which the
tube is to be filled by the simple process of giving it a squeeze. The
trochar, which accurately fits the canula, can only be withdrawn so far
as to open the communication with the side tube. It will be seen that
with such an instrument air cannot get into the pleura.
Of I'ourniquets we have ample supply. Signoroni's clamp tourniquet,
Salt's plain band of steel, Key's expanding tourniquet are all good in
their way. For field purposes Signoroni's, with Archimedean screw at
the hinge, is the most rapid and powerful. It can be applied, and the
limb amputated in half the time that Petit's would take to adjust.
Bandages. — MM. Mayor and Rigalb have proposed to substitute hand-
kerchiefs and napkins for roller bandages. Many of their adaptations are
extremely neat. The old double handkerchief for fractured clavicle is
an example of the system. Others for the groin, for supporting the
breast, and as suspensories for the testicle arc simple and satisfactory:
but a- usual the idea is run t<> distraction by its authors.
* Medical Times and (inzette, March, 1358.
b Goffres on B.indaging. 1854.
4 I [ ' /
ffu* n. The direct application of remedies by i!.i- n
i valuable addition t»> our resources, especially in neural ind
ribly in tetanus. The credit oi originating thii method i^ doe t<» the
.Mr. llynd, who adopted it in the year 1844, and published an account
..i it in the Medical Prem of Ihe year L845." Hit instrument,1 which
expensive, never came into general use, and -Mr. Wood haa obtained the
credit of popularising tin- method. Mr. Rynd need s solution of morphia
in creosote, in the proportion of 10 grains to a drachm, injecting from
to twelve drops, for sciatica along the sheath of the nerve, with excelleni
effect Excellent results are obtained by superficial scarifications over the
terminal branches of the affected nerves, and by painting the scratches
with a solution of morphia in creosote and chloroform. This has been
DSed by Dr. Jameson, of Mercer's Hospital, for many years.
As a Styptic, the perchloride of iron has come into favour; and its
solution has been introduced, with some temporary benefit, into the
slou^hin" and bleeding masses of fungating cancers. Of its use in
aneurism mention has been elsewhere made.
For Local Anesthesia, ice has also been used, and also as a styptic. More
was, perhaps, expected from it in both capacities by Dr. Arnott ; but
there is no doubt, on the one hand, that the steady application of cold is
of great service in retarding the growth of the more acute tumours, ami
on the other, that its value as an anesthetic for operative purposes is
limited to cases of minor importance, such as operations for onyxis or
onychia.
TRANSACTIONS OF THE ASSOCIATION OF THE FELLOWS
AND LICENTIATES OF THE KING AND QUEEN'S COLLEGE
OF PHYSICIANS IN IRELAND.C
SESSION 1861-62.
Third Meeting, January 15th, 1862.
(Open to Visitors.)
Dr. Corrigan, President, in the Chair.
Dr. Jonathan Osborne read a paper on the mode of using a heated
thermometer, which he proposed to call The Animal-heat Thermometer, for
the purpose of measuring the cooling poiver of the air on the human body.6-
a Dublin Medical Press, March 12, 1815.
b Figured in our August Number, 1861.
c These reports are supplied by Dr. B. G. Guinness, Secretary to the Association.
d See a paper on this subject at page 273.
Transaction* of the College of Physicians in Ireland. 115
I)k. Be vi i v read a paper
On so-called Hydatids of tht (Items. — -lie considered thai the name was
incorrect — that tin- disease was <>ne, aoi of the uterus, but of the ovum,
and of very rare occurrence. Notwithstanding many eminent opinions to
the contrary, lie wafl 1 1 i 1 1 1 -t ■ 1 1 satisfied that the true hydatid is never found
in the virgin uterus, but was solely t\wr to impregnation. He considered
it an enlarged and dropsical condition of the \illi of the shaggy chorion;
in fact, a vesicular degeneration of the ovum. lie stated that the patient
so suffering was peculiarly prone to hemorrhagic discharges from the
uterus — indeed, that this was an invariable accompaniment of the disease ;
often reducing the system to the lowest ebb, and a most dangerous
affection.
Dr. James F. Duncan read the following paper: —
Case of Obstructive Disease of the Heart, probably resulting from Chronic
Pneumonia, and inducing Apoplexy. — Edward Fetherston, aged 38, a
carpenter, a man of sober and well-conducted habits, had uniformly
enjoyed excellent health up to the commencement of his present illness.
With the exception of an attack of sciatica three years previously, he
never had any other form of rheumatism, nor any aifection referrible to
the heart.
On the afternoon of Monday, February 10, 1862, when engaged in his
ordinary work, he was suddenly seized with a queer sensation all over him,
affecting the right side of his face in particular. His right hand dropped
powrerless at his side, and his speech became indistinct. Consciousness
remained unaffected, and he did not fall.
He was removed to the Adelaide Hospital on the 11th, and, on examining
him next day, the symptoms he presented were as follow : — His complexion
was clear but pale, and almost anemic, giving the observer the idea that
he had lived temperately, but was suffering from some form of hemorrhage.
His speech was almost inarticulate from indistinctness, but intelligence
and memory seemed unimpaired. There was imperfect paralysis on the
right side ; he could move his hand and leg, and grasp with his fingers,
but with less power than on the left side. The mouth was slightly dis-
torted, and the tongue divaricated sensibly to the right. There were no
symptoms of fever; his skin was cool; his tongue moist, and tolerably
clean ; and the general functions unaffected. The urine was of ordinary
amount: 1020 in specific gravity, and not albuminous.
Though I had no special reason, from the man's appearance or history,
to suspect anything wrong with the heart, I proceeded to examine it, and
was at once struck with the extreme irregularity of its motions and sounds.
There was no unnatural dulness on percussion over the precordial space,
but the impulse was remarkably weak : the sounds were feeble and
confused. Over the greater extent of the heart's surface no murmur could
II'". '
;ted, but the first sound had lost its natural eh
and more « -lit-kv than usual; wad on the hack of the chert, correspond
,1... tit the inferior ai the left scapula, where both sounds could
distinctly heard, they bore a do nblanoe to that of 1 1 1* - fetal h<
in utero, An obscure and badly develope I sj itolie bruit was audible o
one small spot near the apex of the left ventricle, about an inch and a half
below the mamma, and to the left. The radial pull sponded to the
condition of the heart; it was quick, faint, and irregular, giving the
impression that the calibre of the vessel was not adequately filled.
No dyspnea was observable, neither was the respiration accelerated, and
the patient complained of no cough; but a careful examination of Ids
chest discovered double pneumonia occupying the lower portion of each
lung, indicated by dulness on percussion, obstructed respiration, and fine
crepitus. The transmission of the cardiac sounds to the back, pointed to
the same state as the cause of the phenomenon. On close inquiry the man
admitted that he had a cough, and oppression of his breathing for about
three weeks.
I think an interesting question arises in connexion with the symptoms
just detailed — how far they Stand related to eaeh other, and what is the
precise nature of that relation? Are the three sets of symptoms — namely,
those referrible to the nervous system, to the heart, and to the lungs —
altogether distinct from eaeh other, and independent, or is one in any sense
the cause of the other, and, if SO, what is the chain o^ causation ?
i onfeSS that when I first Commenced my examination of the patient's
heart, knowing the intimate and frequent connexion subsisting between
morbid states of the brain and of the great central organ of circulation, I
was quite prepared to discover evidences of some disease existing there,
although unsuspected by the patient himself. Ltit I was certainly taken
by surprise when I discovered, instead of the signs of regurgitation through
the mitral and aortic orifices — which I believe to be the most common link
in this chain — evidences which pointed rather to some obstruction to the
current of the circulation. Hastily adopting, on the moment, the idea that
this obstruction depended 14)011 narrowing o( the mitral orifice, I naturally
inferred that the patient must have been Buffering for a long period — \ ears,
perhaps — from cardiac disease; because such a degree of contraction as
was here indicated was not likely to be produced, except after a long
interval of suffering. But on questioning the patient, to ascertain the
truth of this conjecture, neither his past history, nor the physical si
which he presented, corresponded with this hypothesis. He had never
had palpitation, dyspnea, or pain ; neither bad he hemoptysis, enlargement
of the right chambers of the organ, pulmonary congestion, nor any swelling
of the great veins, all of which usually accompany narrowing of the mitral
opening.
Rejecting, then, for these reasons, the idea that the attack of apoplexy
Transactions of the College of Physicians in Ireland. 117
depended upon a chronic Lesion of the heart, and thai tin; pulmonary
inflammation was ;i mere coincidence, I was Led to look upon the case In
a different poinl <>i* view, and to regard the pneumonic seizure as the
starting poinl of the rutin1 series of the morbid actions; giving rise, in
the arsl instance, i<> changes in the condition of the hear! sufficient to
interfere with the proper performance of its functions, and to the fit of
apoplexy as the remote consequence of these changes. The mode in which
these effects have been produced was, probably, the formation of a fibrinous
coagulum within the Left ventricle, interfering with the free action of the
valves, and with the current of the blood in its passage through the
chamber. After the formation of this coagulum there was, possibly, the
detachment of some loosened portion, in the manner described by Dr.
Kirkes, which, carried into the general circulation, became entangled in
one of the cerebral vessels, and, by its mechanical interference with the
nutrition and functions of the part, gave rise to the symptoms of apoplexy.
To this view of the case several objections will at once suggest them-
selves. In the first place, it will be considered extremely improbable that
coagulation of the blood should occur in a healthy young man labouring
under pneumonia ; for, if it did, the occurrence, instead of being a rare
phenomenon, which it undoubtedly is, should be one of the most common
in the course of practice ; and, secondly, the cerebral lesions described by
Dr. Kirkes have been hitherto found only in connexion with endocarditis
or warty growths upon the valves ; whereas, in this instance, the physical
signs have been different from those accompanying either of those patho-
logical conditions.
In reference to the first of these objections, it is to be remarked that the
attack of pneumonia under which the patient laboured, must have been of
a low and chronic form. For three weeks, according to his own account,
he had a slight cough, and a sense of oppression in his chest, yet it neither
hurried his respiration nor produced any inconvenience sufficient to induce
him to look for medical assistance ; and when he came under observation
in the hospital, though the lower portion of both lungs, posteriorly, was dull
on percussion, yet the fineness of the crepitus, and the absence of bronchial
respiration, showed that the inflammation was still in its first stage.
The chronic form which the inflammation assumed in Fetherstone's ea-e,
and which, doubtless, depended upon some peculiar condition of the con-
stitution, appears to me to furnish some explanation of the phenomenon
in question — assuming, for the moment, that the hypothesis we have laid
down is the correct one. Two circumstances combine to favour the
formation of a clot in a pai't so well iitted to receive it as tic interior of
the left \ fin ricle : the one i- the hyperinosed condition of the blood in the
inflammatory state; and the other is tin- retardation of the current of the
circulation, owing to the pulmonary obstruction ami the impaired energy
of the vital force.
\ [ > f the i ' \nd
I \\ the blood do rionaUy und illation during
fact loo w ill established in pathology to admit of question. I if in the
«>1 I and debilitated, shortly before death, thai it has usuallj b
in whom the waning powers of life are insufficient to maintain th>- circu-
lation in i way to prevent this effect taking place. 1 have met with m
than one instance <>t' late, which 1 had the opportunity of verifying byj
mortem examination, and which, during life, presented physical n
bearing a close resemblance t<> those presented by th under
consideration. These were : weakness and irregularity in the heart'i
impulse, diminution in the volume of the pulse, feebleness in the first
sound, and absence of any bruit.
With regard to the other objection, it maybe said that the attention of
practitioners lias been too recently directed to this form of accident to
enable US to say that it is only in the case of organised growths, detached
from the internal membrane of the heart, that apoplexy can result. The
general principle involved in Dr. Kirkes1 cases applies to all cases of
plugging of cerebral arteries, whatever be the nature of the obstructing
medium ; and while a portion of coagulated fibrin may be less likely to
lead to permanent disorganisation of the brain substance than warty
growths of a denser structure, the immediate effects must be nearly the
same.
Of course, in speaking of the case to which I have called attention, I am
at present only adducing this idea as a probable conjecture; for the
opportunity of verifying the truth or falsehood of the opinion has as yet
happily been withheld. Still, the continuance of the patient's life, or the
removal of the paralytic symptoms, does not necessarily invalidate the
theory put forward. Even Dr. Kirkes admits that the obstructions of
which he treated were, possibly, not in all cases absolutely fatal, but that
the recuperative or adaptive powers of nature may, perhaps, in some
instances be capable either of absorbing the obstruction, or, by dilating
the vessel, allow a sufficient quantity of the vital fluid to pass to the
remote side of the vessel, and so provide for the future nutrition of the
parts beyond.
The treatment I was led to adopt was principally directed to relieve the
pulmonary inflammation, but was equally calculated to promote the activity
of the absorbents generally. It did not differ materially from that usually
employed for such a purpose. In addition to the local detraction of blood
by leeches and cupping, there were used diffusible stimulants, and pills
containing moderate doses of the blue mass, in combination with quinine
and dried soda. The progress of the case has been hitherto satisfactory ;
the paralytic symptoms are decidedly relieved ; he speaks nearly as dis-
tinctly as in health ; the appearance of the face is natural ; and the tongue
is protruded straight. His chest is clearing up ; the dulness posteriorly is
diminishing ; the heart is no longer audible below the left angle of the
Trmisactiotis of the College of Physicians in Ireland. 44!)
Boaprda, or, If al all, very indistinctly, and the crepitus is gone, while air
enters the pulmonary structure more freely. The condition of the organs
of circulation is as yet hut little changed. The impulse, though stronger,
i^ weak; the heats irregular in nuinher and in force; the sounds present
somewhat the same character as they did at first They arc rather
more developed, as if the heart's action were less interfered with. The
systolic bruit is a little more distinct and prolonged. The patient's mouth
is now sore; his Strength has been sustained by wine and nourishment;
and to-day he has been put upon a mixture of infusion of polygala with
hydriodate and carbonate of potash.*
Before concluding, allow rac to add a brief note of a case which I met
with last year, and which appeared at the time to have been an instance
of embolic detachment, although we were unable to satisfy our curiosity
by a post mortem examination.
Julia Dunn, aged 19, a dressmaker, was admitted into the Adelaide
Hospital, March 12, 1861. For two years previously she had been subject
to palpitation of the heart, aggravated occasionally by the occurrence of
general dropsy. She never suffered from rheumatic fever, and did not
know to what the affection of the heart is to be attributed. The symptoms
which she presented on admission were : — Palpitation, cough, with a sense
of constriction, but no dyspnea. There was slight oedema of both ankles,
with constant pain in the right one, increased at night. She was liable
to frequent attacks of epistaxis, and complained of a swelling of some
description in the left hypochondrium. She was a remarkably silent girl,
seemed depressed in spirits, and had an anemic, unhealthy aspect. A
well-marked pulsation was observable above the sternum, whether venous
or arterial was not certain, but a venous murmur was distinctly audible
over the internal jugular. Percussion in the cardiac regions showed the
existence of greatly increased dulness, as well as at the base of both lungs
posteriorly. Over the base of the heart a bruit was heard, with the second
sound ; at the apex a murmur attended both sounds.
The next day the sounds of the heart did not present the same character
as they did the day before, from which circumstance we were led to
predicate the existence of endocarditis in a slow but progressive form.
The day after (the 14th) the murmur was louder, and the pulsation over
the sternum communicated a thrill to the finger placed over it. On the
17th the gums were tender, and a mercurial fetor was perceptible on the
mouth. The pulsation over the sternum was less. She felt and looked
better ; some colour was returning to her cheek ; her cough was gone, as
a The patient continued to improve, but left the hospital on February 2Sth. At
that time the changes in the condition of the heart indicated a material removal of
the supposed mechanical obstruction to the current of the blood. The pulse became
fuller, firmer, and less irregular ; the impulse stronger ; and the bellows murmur over
the apex of the left ventricle more developed.
VOL. XXXIII., NO. 66, N S N
■ts of t/ie Dublin I ty.
well ti the pain in the right ankle. On the. L8th there ill fart)
improvement; and on the 19th, at nine ..'dock ii.m., the told the nm
that Bhe had h.nl a very good night'i sleep, and that she felt better than
had done since her adtaianon. Shortly afterward*, irhen making my
visit, 1 found her crying hysterically, and complaining <>f i pain in her
head and in her stomach, I was led, by her appearance and manner, t<>
think that she had been frightened by another patient, who vrai moaning
in the ward. At 11 o'clock she had a kind of lit, working convulsively,
so as to render restraint necessary. Every two or three seconds -he would
suddenly move her face forward, open her mouth to its wid- :it, and
spasmodically thrust out her tongue, accompanying the act by a prolon
pendulous moan. In tossing her arms about she would bring her hands
to her head, and draw them forcibly across her face, uttering complaints
about her head, as if suffering from pain. The violence of the fit subsided
soon after the administration of an enema, when she remained quiet, but
moaning, and rubbing her face with her hands. She appeared only
partially conscious; for although when spoken to loudly she could still
indicate her head, and mutter something about pain, she would immediately
relapse into a lethargic condition — her eyes half closed, the pupils con-
tracted to their smallest possible size, and perfectly unaffected by light.
The pulse was peculiar, presenting a double impulse, followed by a single
one, which was succeeded by a prolonged interval. There were occasionally
complete intermissions, and again it would be regular, but very weak.
At 12 o'clock she was still able to point to her head, and mention some-
thing about pain ; but this was the last time she spoke. Her breathing
soon after became stertorous ; at a quarter before two o'clock the same day
her pupils were observed to become suddenly dilated to their fullest extent,
and at the same instant the heart's action finally ceased.
PROCEEDINGS OF THE PATHOLOGICAL SOCIETY
OF DUBLIN.*
TWENTY-FOURTH ANNUAL SESSION— 1861-62.
Dr. Banks, President.
Intra- Capsular Fracture of the neck of the Femur. — Dr. Edward
Hamilton said that the specimen before the society was one of ordinary
fracture of the neck of the thigh bone.
It was taken from a female aged, at least, eighty years. She was a
charwoman by occupation, and was admitted into Steevens' Hospital in
consequence of the effects of a fall. She slipped on a flag in a kitchen,
* These reports are furnished by Dr. R. W. Smith, Secretary to the Society.
Reports of tlm Dublin Pathological Society. 451
and foil with Considerable violence to the ground, and was unable to
raise herself. lie saw her the morning after her admission, and she
presented all the features, or most of the features, of intra-rapsular iV;ie-
ture of the neek of the lemur, tolerably well marked. The limb was
half an inch short, and she was unable to raise her heel without the
manoeuvre SO frequently adopted in such cases, of drawing it along tie-
bed. He could not discover the least crepitus; the nimia dtUgenHaWBB
avoided, as they were not anxious to disturb her unnecessarily, and think-
ing that the diagnosis could be satisfactorily made without it. She was
placed on an inclined plane of pillows, and things continued in the same
state for some days. One of the most remarkable features about the
case, was the small amount of suffering ; in fact, she would not believe
that the limb was broken ; she said she was merely bruised, and that
some of the sinews were started. In about the seventh day after her
admission to the hospital, he observed a marked change in her appearance.
It was evident that the flame of irritative fever had been lighted ; her
skin was hot ; her pulse was fluttering, weak, and intermittent ; but,
notwithstanding all these constitutional disturbances, she complained of
no pain in the region of the hip. She sank, however, in a day or two
afterwards. The post mortem examination showed that their diagnosis
had been tolerably correct ; but, he should say, they were, to a certain
extent shaken in their diagnosis, when they found her complaining of so
little pain. There was a slight contusion on the hip, beneath which
there was a small quantity of extravasated blood ; the capsular ligament
of the hip joint was uninjured, but swollen, as it contained fluid. On
opening it a quantity of purulent serum escaped. There was no vascu-
larity, and but little attempt at repair. The fracture seemed as if it had
taken place after death. The clinical teaching of that case should
impress on their minds what most of them knew very well — that there
may be absence of crepitus in cases of fracture of the neck of the femur ;
secondly, that in persons of extreme age the suffering is very slight;
and thirdly, that death arose from irritative fever. — December 14, 1861.
Fibrous tumours of the Uterus. — Dr. M'Clintock exhibited the uterus,
with its appendages, and a part of the vagina, removed from a patient
who died in the chronic ward of the Lying-in Hospital, some weeks before
the expiration of his mastership of that institution. The specimen, by
itself, as a piece of morbid anatomy, was one of considerable interest, and
very instructive. It exhibited almost an epitome of the principal
anatomical characters belonging to that common, but very important,
disease — fibrous tumour of the uterus ; and it presented the chief varieties,
as to situation and structure, of this description of morbid growth.
Tumours of this kind were described by Baillie under the name of fleshy
tubercle ; by Hooper they were called cartilaginous tumours ; and by later
N 2
Dublin Patholo
pathogolists they ha, i \ ario
Iff, Paul Broca, hy iercma,
tin- upper and lot l lide of the uterus were two I ib-peritonea]
tumours; and there were others, in different stag* rowth and
development, protruding from the exterior surface of tin- organ. Th
tumours might be termed gregarious, for they rarely occurred singly;
many as fifteen <>r twenty were sometimes found in the same case, and in
this instance, there were certainly seven; one of those which protruded
from the left Bide of the fundus of the uterus was, so far as shape went
rentable polypus, but covered with peritoneum, instead of mucous mi
brane. It was attached to the uterus by a small, fiat, ribbon-like neck,
and had a very white dense structure.
This tumour was in the first Stage towards calcareous transformation,
a spontaneous process of cure, depending in a great measure on
diminished vitality. Attention lias lately been drawn to the transplan-
tation of fibrous tumours from the uterus to other parts of pelvis, and the
way in which this occurrence took place was satisfactorily explained in a
paper written on the subject by Dr. Turner of Edinburgh.
The tumour, in the case before the society, might be regarded as in a most
favourable state for such transplantation, in consequence of the length and
BmallneSS of its pedicle. So far for the sub-peritoneal tumours. Another
situation for fibrous tumour was in the substance of the uterus, and when
so placed the uterus became enlarged in size and developed in structure ;
whereas the sub-peritoneal tumour exercised but little influence on the
iwth of the uterus, and caused scarcely any annoyance. In the present
instance an interstitial tumour has produced a very great augmentation in
the bulk of the uterus, with great thickening of its walls. The third
position of the fibrous tumour, was where it protruded from the uterus
into the vagina, forming a fibrous polypus, or pediculated submucous
iibrous tumour.
There was on the table a magnificent example of such a polypus. We
now come to the clinical history of this specimen. The patient was un-
married, and had been suffering from continued hemorrhage for five
months before her admittance into hospital On examining the state of
the uterus, this large polypus was found to exist, and the patient was
admitted for operation. The next morning, having made a more minute
investigation, Dr. M*C. discovered that the woman was thin, haggard-
looking, and very much anemiated, and altogether in a very unpromising
state for an operation. The uterus was evidently much enlarged, there
was a large tumour above and to the left of the pubes. It was elearly
not a case of simple uncomplicated polypus. On further examination per
vaginam, they observed a watery fetid, discharge. On consideration of
these circumstances it was decided that the case was not a suitable one for
operation. Dr. Marion Sims, of New York, was at this time in Dublin,
Reports of the Dublin Pathological Society '• 153
ami a very frequent visitor of the hospital Dr. BCC. showed him the
ease, and told him that he hesitated to remove the polypus. Dr. Sims
entirely concurred with him as to the inexpediency of the operation, and
added thai in his own hospital, if the operation were to he undertaken,
he would hi> apprehensive of a fatal pyemia succeeding to it. This
decision wu conn- to on a Wednesday morning; and on the Friday
morning she got a rigor, followed by vomiting, abdominal pain, ami col-
lapse, and she died in ten hours. A careful post mortem examination was
made. There were traces of incipient peritonitis, and a good deal of fluid in
the lower belly. A rupture of a cyst in the right ovary was detected, and
the fluid, still remaining in the cyst, was the same in appearance as that
found extra vasal ed in the peritoneal cavity. If any operation had been
performed her death would, no doubt, have been attributed to it; so that
it was fortunate they had abstained from interference. The cause of
death was most interesting and important. — January 11, 1862.
Diabetes. — Dr. Moore said that the specimen which he was about to
show was taken from a man who was admitted into Mercer's Hospital on
the 14th of October last. The case was very closely watched, and was
one of great interest. He would read the history of the case : —
Patrick Ryland, aged 43, a pensioner; had served 21 years in the 23rd
Regiment, in many parts of the globe ; and in 1858, after his return from
India (where he had been laid up for three months with rheumatism) he
was discharged. About the middle of March, 1861, he first felt cramps
in his legs, and began to lose flesh. During the month of April he became
more emaciated, his thirst immoderate, and his urine greatly increased in
quantity. In June these symptoms were still more aggravated, and on
the 12th of this month he was admitted into St. George's Hospital, under
the care of Dr. Bence Jones. He came to Dublin in September, and was
admitted into Mercer's Hospital on the 14th of October. On admission
his symptoms were : — Extremely haggard, emaciated, anxious look ; skin
hot and dry ; immoderate thirst ; abnormally increased secretion of urine,
of a pale straw colour. He complained of pain in his chest and down his
limbs ; of impaired vision, particularly the left eye ; of extreme cutaneous
sensibility, the slightest touch making him wince. The physical signs
were : — Appreciable dulness under the right clavicle, and over both lungs
posteriorly and inferiorly ; feeble respiration, with a short, dry cough.
1 lis diet, on admission, consisted of one pound of bread, one pint of milk,
and one egg ; one pound of beefsteak, one quart of beef tea, one pint of
milk in the evening; one quart of milk and lime-water during the 21
hours. The first 24 hours after his admission he passed 10 pints of urine.
specific gravity 1046, having an acid reaction, and loaded with sugar,
when tested with liquor potassse. He was now allowed a pint of porter.
The quantity, or specific gravity of the urine, did not materially vary till
Dublin Pathological &
the lsth, when, the patient havi Lfl pinti bn ki _i
hours, with u specific gravity of 1040, Pi n inghtoo found the
proportion it to be 7*98 grains to the pint — about 23^ our
in the 'J l hours. The specific gravity of the urine remained tlie same until
the 28th, when it rose to 1050. On the 29th the patient passed 'J pints of
urine, the speciiie gravity being L048, ami the proportion ok sugar, ae-
oording to Professor Hanghton's calculation, was 7*00 grainf to the pint.
Things went on the same way for some time. The specific gravity of the
urine was reduced to 1025. On the 1 1th of November his diet was changed,
and he was allowed a considerable quantity of greens. On the lL'th lie
only passed BU pint- of urine, the specific gravity being 1040. Although
he was allowed to drink water ad libitum, it did not seem to affect the
quantity of urine he passed. On the 13th seven pints of urine, with a
specific gravity of 1040. His expectoration now became more copious,
and was like treacle, and sweet to the taste. Nothing remarkable occurred
until the 24th, when gargouillement became well marked under the right
cla\ icle, and there was oedema of the extremities. On the 25th the specific
gravity of the urine was 1030, and the quantity passed four pints. On
the previous day it was 1040. On the i)th of December he passed five
pints, and the specific gravity was 104G. There was evidence of the
right lung breaking up. On the 10th lie passed four pints ; the specific
gravity was 1010, and there was not any sugar. That was so staggering,
that the patient, having been put sentry on his own urine, was much
affected at being suspected of interfering with it. At this time he was
suffering from pain in the side, and was unable to take a deep inspiration.
On the 11 th he passed four pints : specific gravity, 1030. On the 16th
the specific gravity wras again up to 1042, and Professor Haughton found
that the sugar had fallen to 1*40 grains to the pint. On the 17th he passed
three pints, and the specific gravity was 1017 : no sugar. There was
crepitus over the mammary region of the left side. On the 18th he passed
six pints, ami the specific gravity was 1036. On the 19th it was again
up to 1042. On the 21st he passed six pints, and the specific gravity was
1006: no sugar. 22nd, it was 1032: sugar presented. 23rd, 1014: no sugar.
From that day to the 3rd of January, when he died, there was no sugar.
The postmortem examination disclosed no very striking appearances. The
kidneys were slightly enlarged, as they are found in these cases. Hyperemia
was extreme. They weighed three ounces over the average weight. The
spleen was small, and there wras nothing abnormal in the condition of the
liver. The heart was comparatively small ; it weighed over nine ounces.
The right lung gave evidence of disease from an early stage, and was one
mass of tubercle, which, in the upper and middle lobes, had run on to
general breaking up. The left lung was studded with tubercles. He wras
induced to bring forward the case for various reasons, but more particularly
on account of its intermitting character writh regard to the disappearance
Report* of the Dublin Pathological Society. 455
and reappearance of sugar. Cases bays been brought forward in which the
quantity of sugar gradually diminished before death, but he had Dot seen
i ease in which these intermissions occurred. The Loss of \ ision, particularly
of tlu' left eye, did not pass unnoticed, .Mr. Hildigc having examined both
ayes by means of oblique illumination, when not the slightest opacity of
either Lens or capsule could be detected. The retina of the left eye pre-
sented the following appearances: — The optic nerve was <<f a blood red
Colour al the point where the arteria centralis retina and vein (Miter it ;
near its circumference the colour was somewhat lighter, but it was marked
here and there with spots of apoplectic exudation. Between the entrance
of the optic nerve and the macula lutea, the retina presented a yellowish
white appearance, resembling a parallelogram in shape. This extended
about one-fourth of an inch above and below the optic nerve, following
the course of the vessels, and ended abruptly in a somewhat serrated
though well-defined margin. The macula lutea itself was but slightly
changed in colour, and the remainder of the ground of the eye was normal ;
the field of vision was reduced to about one-eighth of its normal extent ; so
that when the eye was fixed on a certain point, and the hand moved round
this point at a distance of about eight inches from it, it could not be
discerned. Although the sight of the right eye was relatively unimpaired,
still it was found, on examination, that the optic nerve of it also was much
redder than natural, and feint greyish spots, resembling the first stage of
sclerotico-choroiditis posterior, were observed here and there over the
ground of the eye, particularly in the neighbourhood of the macula lutea,
and following the course of the retinal vessels ; however, the sight of it
enabled the patient to read ordinary type without the aid of glasses. —
January 11, 1862.
Phthisis — Tubercular abscess finding exit through the intercostal space. —
Dr. Hayden said that the specimen he exhibited was taken from the
body of an aged female who was admitted into the Mater Misericordiae
Hospital, on the 29th of November. She exhibited all the signs and
symptoms of phthisis in an advanced stage, including, amongst the
former, well marked gargouillement in the right infra- clavicular space.
It was unnecessary to detail the symptoms. He observed, however, that
there was more than ordinary cutaneous sensibility under the right
clavicle ; and she could scarcely endure the slightest contact of the
stethoscope in this situation. Shortly afterwards, he remarked a tumour,
measuring three inches by two, in the situation where the patient com-
plained of tenderness ; the tumour appeared when the patient coughed,
and subsided immediately afterwards; and on manipulating it by press-
ing witli the thumb between the third and fourth ribs, it did not appear
as usual, when she coughed ; it was emphysematous and resonant on
percussion. A variety of means to allay the irritability were tried writh-
/ ',' Dublin Pat)
out i found to i mi
! he tltcd on the evening of the 1 5th instant. He w
ird the iiuuuiir as the renilt of the escape of tubercular
.11 the lung, perforating both layers of the pleura, and fin li:
between the third ami fourth rib*. He ftlfO Supposed, from pi.
ration, which it was rerj difficult to make, owing to the extn
emaciation of the patient, that the matter had found exit through qui
the bronchial tubes. There was crepitus in the cavity when she COUgfc
and air passed freely through the opening from the lung into the abec
inflating it. A closer examination induced him to change this opinion,
Chiefly from the fact, that he was unable tu discover the usual metallic
phenomenal The result of the examination showed that his first impi
sion was correct. Mr. Ryan, the resident assistant, removed from tin-
thorax the integuments, subcutaneous tissue, and a portion of the second,
third, fourth, and fifth ribs, with their corresponding cartilage, and tin-
entire of the upper lobe of the lung. On raising the integuments with
the muscles, he found his lingers in a large cavity, lined at the outer
side by a dense membrane, as thick as leather. The ribs were denuded
of periosteum, and carious on the surface, but there were grounds, he
thought, for concluding that the abscess was not the result of caries
commencing in the ribs. On closely examining the inner wall, he found
a distinct communication between the portion of the lung which i
attached to the ribs and the surface of the cavity, an aperture about the size
of a goose quill. They might form a number of conjectures in this ca
but, under all the circumstances, he was disposed to regard it as one of
tubercular abscess, finding exit through the intercostal space, and so into
the superficial structures, lie remarked that the great elasticity of the
walls of the cavity, and the existence of a second opening at its lower
part might explain the absence of metallic phenomena by preventing the
accumulation of liquid within it. — January 18, 18G2.
Syphilitic Laryngitis. — Dr. E. Hamilton said, that the specimen which
he was about to bring under the notice of the Society was taken from
the body of a female 60 years of age. She was admitted into Steevens'
Hospital suffering from what she called sore throat ; but an examination
proved that the disease was not confined to the throat. The history she
gave was, that the disease had been of four years' standing.; that she had
repeatedly applied for relief to different hospitals in the city ; and had
taken medicine on her own responsibility, but never got completely well.
She also stated that she had reason to believe that her husband had been
unfaithful to her and had given her syphilis. She, however, never had
any symptoms, with the exception of sore throat.
Her throat showed evidence of extensive ulceration, the result of
secondary syphilis. Her health was broken down. The ordinary means
Reports of the Dublin Patliological Society. 1 r> 7
having failed to arrest the ulceration, the treatment by mercurial fumi-
gations was adopted; under thia she improved considerably, but still
the laryngeal distress was very great* She usually had paroxysms
ai nighl ; and during his visit in the morning he saw her in one of
(hose. He considered whether he would not be justified in performing
the operation of tracheotomy, in order to relieve her. However, he
did qoI do bo thru, feeling quite satisfied that Mr. Byrnes was quite
OOmpetenI to ad in case of emergency. Things went on the same way
for some time. On the evening of the 14th November, she had a violent
attack of dyspnea, and Mr. Symcs, finding that there was no time to be
lost, immediately performed the operation, after which she experienced a
quiet night. He saw her the morning after the operation, when she pre-
sented all the symptoms of extreme depression. She improved from day
to day and passed a considerable time without any laryngeal distress.
She was able to sit up and eat solid food. The disease seemed to have
passed off. About three weeks afterwards she got up during a cold
damp night to close the door ; and the next morning he found her suffer-
ing from all the symptoms of intense bronchitis, which resisted all efforts
of treatment, and she at last sunk under it. All the symptoms of disease
had passed away ; and, but for this woman's own indiscretion, she might
have left the hospital well. He might allude to another case, almost
precisely similar, which occurred some time ago, and was under the care
of Mr. "Wilmot. He was called on to operate, and the man shortly
afterwards was able to leave the hospital. Subsequently, whilst working
at the King's-Bridge, the tube, which he was in the habit of putting in
himself, came out, he endeavoured to insert it as usual, but, becoming
confused, and losing his presence of mind, it was necessary to bring him
to hospital, as he was in a state of complete asphyxia. The object in
performing the operation should be to prevent rather than to relieve
asphyxia. — January 25, 1862.
Disease of the Mitral and Semilunar Valves. — Dr. MacSwiney said, the
danger of engagement of the heart, and the irreparable injury which
may be inflicted upon that organ during the progress of a case of acute
fibrous rheumatism are, unfortunately, but too well known. In the series
of cases of this disease reported by Bury (British and Foreign Medical and
Chirurcjical Review), 476 in number, more than half, or exactly 253, were
complicated with heart affection of some kind ; and the specimen which
I bring before the Society to-day affords, in its pathological condition,
abundant illustration of the same fact.
This heart was removed from the body of a man, aged 27 years, who was
admitted into Jervis-street Hospital under my care, in the beginning of
December last, and died in about three weeks after he came under my
observation. He was a tailor by trade, and had been of intemperate habits.
Dublin Pat)
[ n red the following histoi M... at four j tftera 1
«l« al oi >ld and wet, he was attacked with an scute illness,
• uipunifd with pain and fever, in fact, \\ it li what we rail rheumatic
r. Hi- wai taken to tin- Hardwicke Hospital, and was placid under
tlir t Dr. Banks. He remained there for about six s snd
then left quite well, at Least, not conscious of anything ben sg with
him. After that he was subject, from time to time, to rheumatic pains,
ami had, occasionally, epistaxis. A brother of his had died of con-
sumption about a year ago; but no other member of the family had
had rheumatism.
Upon admission he presented the following appearances: — His aspect
was pallid and delicate; his respiration was quick, and somewhat diili-
cult ; under his eyelids was puffy ; his face, generally, had a swollen look,
and there was a slight hectic blush upon each cheek. His legs and l
were cedematous, more particularly about the ankles ; and he had some
general anasarca. He had cough which was distressing, frequent, loud,
and he brought up a quantity of mucous and watery expectoration, which
was now and then tinged with blood. His voice was laryngeal, and at
intervals he had almost complete aphonia. His pulse was quick, full,
and hard, but quite regular. There was no visible pulsation in the
sels of the neck. He had attacks of orthopnea, but was usually able
to lie clown, and when he did, the decubitus Avas on his back. His
tongue was partially covered with a yellowish white coating ; the urinary-
secretion was scanty, high-coloured, and occasionally giving a reddish
deposit. His sleep was bad ; his appetite moderately good.
The chest sounded clear in front ; the dulness upon percussion, in the
cardiac region was heard over an abnormal extent. Posteriorly there
was dulness upon percussion at the base of both lungs, but this dulness
was not very great — was not absolute. Auscultation in this region
revealed a crepitating rale with large bubbles, such as one might expect
to hear in oedema in the lower lobes of the lungs.
A systolic bruit was heard at the base of the scapula near the posterior
an ode, and in that situation alone. I was never able to hear the bruit in
front, although I frequently looked for it ; the heart's action was loud,
and sometimes tumultuous there ; but I was able at all times to distin-
guish both sounds of the heart, sulllciently to enable me to say that there
was no morbid murmur masking either.
At first, from the cough, the dyspnea, the quick pulse and crepitus,
the pallid look, and more particularly, from the partial aphonia, the
hectic appearance, and the family history, some suspicion of phthisis was
excited in my mind ; but I rejected the supposition, and wrote down the
diagnosis — " heart disease ; probably regurgitation through the mitral
valves ; cedema of both lungs, at base."
I pass over all details of treatment, which was merely confined to
Reports of the Dublin /'at ho logical Society. 459
ilio exhibition of such remedies as, from time to time, lie seemed to
require, to palliate mvjvnt suffering.
Ho had been noticeably worse for some days, but died rather suddenly,
nevertheless, on the 1st of January, 1862.
A pod mortem inspection of the body was made 12 hours after death,
and, I confine myself to reporting the state of the lungs and heart.
The lnngfl were healthy; that is to say, there was no tubercular
deposit whatsoever in them ; but they were, at their lower part, very
much congested, and very red. Still, they crepitated, and portions of this
engorged part floated, when put into water. There was no true pulmo-
nary apoplexy.
A cluster of bronchial glands, very large, and very dark in colour,
almost surrounded the lower part of the trachea, and may, by their pres-
sure have induced the paroxysms of aphonia, and the stridulous breathing
suffered from during life.
The heart was large, firm, and free from fatty degeneration. The
right chambers were healthy ; the right ventricle contained some fluid
black blood. The walls of the left ventricle were thickened ; its cavity
contained a large fibrinous coagulum. The valvular apparatus at the
left auriculo-ventricular orifice was disorganized. There was a permanent
opening, or slit, of an oval form, through which the blood must have in
part regurgitated during the ventricular contraction. The valves were
hard, contracted, and thickened, and there were warty vegetations upon
them in two or three situations.
It may be worthy of remark, in connexion with the sudden death, that
one of the chordae tendineos attached to the valvular edge was ruptured
from the wall of the ventricle ; but whether this occurred post or ante
mortem, I am unable to say.
At the aortic orifice we found two or three small granular vegetations
or warty tumours deposited on the edge of the sigmoid valves, and pro-
ducing, consequently, insufficiency in them. They were no longer able to
fulfil their normal duty of closing the aorta against the recoil of the
blood, as wras proved by pouring water into the vessel, and noticing that
it passed easily and speedily into the ventricle. — January 25, 1862.
Contraction of the Left Auriculo- Ventricular Opening. — Dr. Bannon pre-
sented a specimen of this disease, which occurred in a female under his care,
who died on that day week in the Mountjoy Prison. She was 31 years of
age, and had been for 1G months in prison, having led a very irregular
life. She had been complaining for some time of dyspnea. She had
watery expectorations, occasionally mixed with blood of a dark colour, and
violent palpitations, with severe pain in the region of the heart, extending
all over the chest. Her pulse was weak, unequal, rapid, and occasionally
intermitting. When the expectoration ceased, the dyspnea became violent,
Report* of the Dublin Obstetrical ■ ■
ompanied l»v orthopnea. On examination, I iltation, be found
considerable dulneefl over the region of the heart, and then
■ peculiar soft bruit accompanying the second Bound of th irhich
was audible ■ tittle above tin* apex <>f the heart* There irai al -lit
iiMtaiit murmur during the first Bound, about irhich he could uol
thoroughly satisfy himself. He conceived that there vras disi the
mitral valves, with contracted opening, and he did not think he ever law
a ease in irhich the contraction of the opening iraa found so complete
in this. A mere semilunar slit constituted the aurieulo-ventrieular openi:
ami it was almost closed. The symptoms were very interesting. At i
time, after a violent attack of palpitation, the pulse became exceedingly
slow. She firet tainted, after whieh the pulse eame down to 34, and it
was found, on applying the stethoscope, that the action of the heart *
not so slow as the pulse. He was present on that occasion, and also at
her death. For a considerable time before she died there was no pulsation
in the arteries, but the heart beat on. The heart was hypertrophied to
some extent, but there was no disease of the semilunar valves. The
lungs were congested and (edematous, and universally adherent on both
sides of the thorax. The principal point of interest in this case appeared
to be how life could have been prolonged under a condition of such eon-
traction of the aurieulo-ventrieular opening as was here present. Tin
physical signs were valuable, as indicating the nature, although hardly
the extent, of the disease present during life. — February 15, 18G2.
PROCEEDINGS OF THE DUBLIN OBSTETRICAL SOCIETY. a
TWENTY-FOUUTH ANNUAL SESSION, 1801-
Second Meeting, 21st December, 1861.
Dr. Fitzpatrick, in the Chair.
Dr. Minciiin exhibited to the society an infantile cranium of a re-
markably distorted and unsymmetrical shape. Certain facts connected
with the history of the ease, during life, having tended to invest the
specimen with some degree of obstetric interest, he would briefly detail
all the circumstances whieh had come to his knowledge with respect to
it. When he saw the infant first, it had just been admitted into hospital,
a^ed five months, labouring under diffuse bronchitis. The child was of a
delicate stamp ; the body and limbs had all the appearance of defective
nutrition ; countenance congested and anxious ; there was, however, no
* These reports are supplied by Dr. Geo. H. Kidd, Secretary to the Society.
Reports of the Dublin t >l>stctrical Socief// 461
symptoms whatever indicative of cerebral disturbance, The patient made
ti very fair recovery from the chetl attack, but during its stay in hoepita]
the singularity of it- crania] contour baring become the occasion of no
small gossip among the women in the ward, the mother of the infant gave
the following account of the matter, in reply to the inquiries which Dr.
Minchin addressed to her on the subject, namely : —
Thai she had been delivered of this, her first child, about five months
previously, in the Dublin Lying-in Hospital; that her labour was a very
protracted and difficult one, and was completed with the aid of instruments
of some kind, while she was under the influence of chloroform ; that the
u doctors" had a long account of the child written in a book, and that they
employed a gentleman to make a picture of the child's head.
Having received this account, it was thought advisable to make inquiry
at the Lying-in Hospital; and on searching the records for the case of
M. C. it was found that no patient, of that name, had been delivered there,
at the period indicated by this young woman ; but that on the same day,
and in the same ward, a patient, named H. R., aged 22 years, had been
delivered of a male infant ; that the forceps was employed, on account of
delay in the second stage, (about 10 hours) ; and that the extraction of the
head was not attended with any difficulty whatever. This appeared to be the only
forceps case which occurred at the period named by the woman C, and it
was reasonable to conclude that the cranial distortion, (if any existed),
could not have been very great, else it would have elicited some remark in
the clinical report, every peculiarity worthy of note, in such cases, being
always carefully observed and recorded.
This infant was again admitted into hospital at the age of nearly eleven
months. Its condition at that period was as follows : emaciation extreme ;
skin pale, flabby, and dry ; diarrhoea very urgent ; hard, dry, irritative
cough ; disinclination for food, (it had been weaned about a month
previously) ; there was no unnatural heat of scalp ; nor protuberance of
the anterior fontanelle, which was very large ; nor had convulsions ever
occurred. The child lingered for about five weeks, and died at exactly
twelve months of age.
The autopsy revealed abundance of crude tubercles in the lungs and the
mesentery, with patches of ulceration in the small intestines. The
membrane closing the fontanelle having been carefully removed, the lateral
ventricles were tapped, but the quantity of serum obtained, from both
sides, did not amount to six fluid drachms. On examining the cranial
suture-, the lambdoidal was observed to have a singularly unsymmetrieal
outline, the occipital bone having developed much in excess towards the
left side ; and this fact was strongly opposed to the notion entertained
by the infant's mother, namely, that instrumental compression had given
origin to the obliquity which this part of the head was found to possess;
for, no degree of compression exercised by the forceps, however severe or
L62 Rsporti of ths Dublin 0 ety.
long eontinned, eonld here any action on tin omnia] boota, len thai
altering their relaJ iiion one to Another, (putting fraotnn on-
tusion out of tin.- question) ; it oonld not possibly canes 1 1 1» - natureJ "utline
in v one bone to parens a new and onnena] course. The clinical history
ol the labour, nnin^vi'r, as obtained at the Lying-in Hospital, ii quite
conclusive upon this point. It would appear, therefore, that the abnormity
ihibited in this cranium, was merely an i id
that want of symmetry so commonly observed in infantile heads, and v
connected, in some way, with a delicacy of original constitution, which
gradually developed itself in the form of a general tuberculosis. It was to
be remarked, in this ease, that not only was the anterior fontanelle much
more open than it is usually found in children of one year old, but none
of the teeth had made their appearance.
Mr. TuFNELL read the following ease of Extra Uterine Fetation — Ticin
Conception from the same Ovary — Xormal descent of one fetus into the Womb ;
arrest of the other in the fallopian tube; escape from thence, by ulceration, into
the cavity of the abdomen, followed by hemorrhage, and death in 24 hours.
M. K., a young woman, twice married, and who, seven years before,
had given birth to a healthy living child, was again, on the Gth of July,
18 GO, between three and four months pregnant. Upon the evening of
this day she was in the act of getting into bed, when she was seized with
a sudden and severe pain in the lower part of the abdomen. She had
walked, during the day, upwards of four miles, and was somewhat
fatigued. She was seen about an hour and a half after the first onset of
pain, and had then a weak fluttering pulse, with a countenance pale,
anxious, and pinched. Great pain was complained of over the whole
abdomen, more particularly in the umbilical and right iliac regions.
Upon examination per vaginam, the os uteri was found advanced and
Reports Of the Dublin Ohstetriral Society. 468
slightly retroverted, its orifice contracted* An anodyne ol a. full dose of
opium was prescribed, and wine ordered to be given-; whilst hot jars
ware applied t<> the feet
Five hours afterwards she was Ed the same state, and no stimulants,
ammonia, brandy, or wine, appeared at all to rouse her.
At nine p.m. she expired; haying been ill, from the eommencement to
the close, only t wenty-1'our hours.
Thepost mortem examination was made fifteen hours after death. The
abdomen was bulged out and protruded to a degree considerably beyond
what it would be at this period of pregnancy. Upon opening the walls
upwards of three quarts of fluid and clotted blood escaped, amongst which
was found floating a diminutive fetus. Upon making further investiga-
tion a rent was discovered in the right fallopian tube, out of a cyst in which,
this fetus had escaped. The contents of the cyst seemed to consist of
Qoagula and shreds of lymph.
The fallopian tube and right ovary were agglutinated together by shreds
of recent lymph.
Upon making a more careful inspection of the fetus, the uterus, and
its appendages, the following was found to be the actual condition of each.
The fetus itself was barely an inch in length, and only a few grains in
weight. It appeared to be a male, from the development of penis, but
this growth might possibly be clitoridal. The head and eye, the arms
and hands, and the ribs, were very clearly perceptible, and the spine, with
a cleft at its inferior half. The lower extremities were less fully
developed.
The uterus was enlarged to about the size of the third or fourth month
of pregnancy, and contained a healthy male fetus, proportionate to the
date of conception, connected by the umbilical cord to the placenta, which
was still attached to the fundus uteri.
The fallopian tube on the right side was largely dilated ; the dilatation,
which had been ruptured by the escape of the fetus being one and a half
inches long ; commencing about three quarters of an inch from the uterus,
it contained, at its upper or distal extremity, a solid organized mass,
resembling a miniature placenta. Immediately above this dilatation, viz.,
on its outer border, the fallopian tube was of its natural size, and the
fembriated extremity perfectly natural.
The ovary on the right side was nearly twice the natural size, and
appeared to be divided into two equal portions by a kind of hour-glass
contraction. Upon dividing the ovary through this double enlargement,
by a longitudinal incision, a distinct corpus luteum was seen in each
division, one occupying either of the portions into -which the ovary was
divided.
Upon the left side the ovary and the fallopian tube were in their normal
condition; so that both ova had, in this instance, escaped from the right
of the Dublin Oh
ovary. Ti uteri wus tight] d, and the i and If
had not been known, it might bai conai-
dered ;i primiparous conception.
This woman, then, it ifl clearly evident, died <»t' internal hemorrh
in oonseqnence of the rapture ol the cyst in the fallopian tnbe, and the
escape of the extra uterine fetus into the cavity of the belly.
Fur the opportunity of detailing this case, and securing the preparation,
lam indebted t«> my friend \h-. Lockwood, Burgeon of the Royal Scots
Greys. The preparation is in the museum of the Royal Col]
Surgeons in Ireland.
Dk. Kidd exhibited a dissected preparation of a large congenital
tumour of the head, along with a highly finished coloured drawing, by
Mr. Connolly.
The woman, whose child was born with this tumour, was an extern
patient of the Coombe Hospital ; her labour was not attended with any
difficulty. This was her third child, her previous ones being quite healthy ;
it was brought to the Coombe Hospital the day alter its birth, with the
hope, that the tumour might be removed by surgical operation, and \
admitted with the mother, that it might be kept under observation.
The tumour sprang from the region of the posterior fontanelle, it was
connected to the head by a short pedicle, measuring I inches and
^ in circumference, and 1 inch in length. From this the tumour
swelled out into a globular form, and measured 25 inches in
circumference. It was covered, for the most part, with normal integument,
and for some distance from the head, had hair growing upon it. In some
places, remote from the head, the covering was thin, transparent, and
Reports of the Dublin ( >l>sfrtrical Socio t J/. 465
dark coloured) allowing the parts underneatli t<> be seen through it. The
tumour evidently contained much Moody fluid, and a large quantity of
solid matter, this latter being mod abundant Dear the head. The child
was well developed, in every respect, except the head, which was small,
the frontal region being much (latter than natural. Ii look the bread
Well, and seemed to be a healthy well-thriven infant. It hore pressure 00
the tumour, or on the pedicle, without apparent inconvenience, it seemed
to feel the pressure, but suffered neither from coma nor convulsions.
After some days, ulceration at the thinnest parts occurred, and large
quantities of serum escaped, reducing the size of the tumour considerably.
The child now ceased to take the breast ; and died on the twelfth day,
apparently, from the irritative fever of the ulceration.
Twenty-four hours after death, the roof of the skull, with the tumour
attached to it on one side, and the brain and dura mater on the other, was re-
moved. On reflecting the integument covering the pedicle, a strong fibrous
sheath was found, attached at one side to the edge of the f ontanelle, and con-
tinuous there with the peri-cranium and dura mater, and expanded over
the tumour at the other, in the wTalls of which it was gradually lost. A
section, extending right through the tumour, wras now made. It wras
found to be composed, for the most part, of red, semi-solid substance,
presenting not much trace of organisation. Furthest from the head the
walls were thin, and here there were large loculi, containing bloody fluid,
next the head it was almost solid, but had a small cavity in the centre,
which communicated with the cavity of the dura mater, and in it a small
nodule of cerebral substance was found, not larger than a small unshelled
almond, and which was continuous with the hemispheres of the cerebrum.
The brain, as contained in the cavity of the skull, was found to be perfect in
all its parts, though small. The brain-like substance in the tumour seemed
rather to be an out-growth from the brain, than a part of the brain itself.
As to the nature of this tumour, Dr. Kidd remarked, that two opinions
might be held — 1st, that it was a hernia cerebri, and analagous to the
tumour seen in cases of spina bifida. Against this view the following
arguments, he said, might be adduced : a — the completeness of the brain
itself, as contained in the skull, for, though small, from being deprived of
a portion of the blood intended for its growth, it was perfect in its parts.
b — The perfect development of the child, c — The non-production of con-
vulsions, or coma, on pressing the tumour, d — The shape of the tumour ;
the small pedicle and largely expanded mass, e — Its structure ; the large
quantity of red tissue ; formative tissue, or blastema; and the small size,
compared to the general mass, of the cerebral substance. 2nd — It might
regarded, lie said, as an attempt at the formation of a double monster;
a-, in tact, the first >tagc towards the formation of a double child, such
as the Russian child, whose photograph has been deposited, by Mr. J. S.
Hughes, in the museum of the College of Surgeons, and which consists
VOL. XXXIII., NO. 66, N. S. O
466 Report* o/ihs Dublin Obstetrical Society.
ui kn i perfect children, Adherent to one mother bj the crowns of tl.
beads*
It ii now vreti established, Dr. Kidd said, that double n - are
aed, not by accidental adhesion <>f twin germs, bj taught by St.
Hilaire, but by the excess of development of a single germ — that they
amies, as Yrolik expresses it, M rather of singleness tending to duplicity,
than of duplicity tending to singlenc The researches of Allen
Thompson seem to place this beyond question, he hairing actually ol
the s"n rm in B goose egg taking on the process of duplication.
Nor is it difficult to conceive that it should be so, when we reflect on the
process of development. The single " germ cell " dividing and subdividing
till it forms a mass of cells, the " germ mass," in the centre and at the
mse of which a new cell is formed, and from this, by a similar pTOC
of cell subdivision and growth, the blastema is prepared, out of which the
new being is formed. This blastema is modelled into the several organs
of the new being, under the influence of germs distributed through it.
These germs may be deficient in formative power, when the new being
will be defective in one or more of its parts, as in cases of acephalous
infants, &c. Or they may be possessed of excessive powers, and give rise
to various forms of duplicity — partial, as where the fingers or toes are in
excess, a peculiarity that may run through several generations in
succession — or complete, as in double monsters.
Dr. Kidd referred to a paper he had published in the Dublin Hospital
Gazette, in 1850, (vol. iii., p. 82), in which he had attempted to formularise
the facts ascertained as to the errors of development, as follows : —
"The formative germ is likely to suffer from errors of quantity; of
quality ; and of distribution.
" The quantity of formative power and material may be deficient, giving
rise to some of the deformities attributed to arrest of development.
" The quality may be bad, giving rise to some of the forms of mole.
" The quantity may be in excess, and the quality deficient, giving rise
to such cases as the present ; or
" The quantity may be in excess, and the quality good, giving rise to a
double monster, more or less perfect, according to the amount of excess ;
varying from the supernumerary fingers, to the parasite, and the perfect
double monster.
" Finally, the balance of distribution may be wrong, as in some cases
where part of the body is deficient, and other parts are in excess."
The tumour that formed the subject of the paper referred to, grew
from the hard palate of a well developed child, protruded from the mouth,
and was nearly as large as that growing from the head in the present
case. In it there were germs, distributed throughout the mass, possessed
of very considerable developmental powers ; which produced in one place
a finger, in another a portion of very perfect intestine, and in others
'Reports of the Dublin Obstetrical Society. 4G7
various portions of l>onc, &c. The great mass of the tumour consisted of
tissue analogous to thai forming the mass of the tumour in the present
instance. The Intestine, in that case, presented thii remarkable feature,
that it was doable; in fact, the germ hy which it. "was formed, hud such
an excess of power as to douhle itself, BO that if all the germs had DOSessi -d
similar powers a triple monster would have heen produced, instead of a
merely double one.
In the case now laid before the society, it would appear that an excessive
quantity of material was produced, but of such a quality, or, rather, so
deficient of developmental power, that no organisation took place, except
at the point where the process began, viz. : at the brain, and even there
to a very limited extent.
The tumour springing from the sacrum, laid before the society by Dr.
M'Clintock some years ago, was probably of the same character, viz : an
excessive formation of material without powers of organisation. The
tumour referred to, as growing from the palate, presented the same excess
of material, but with higher power of organisation.
The well-known case recorded by Sir E. Home, where a perfect child
had a head, with a complete brain and well marked features, but no body,
growing from the back of its own head (from the same region as in the
case under consideration), exhibits a further advance in the process ; the
power of organisation being of a very high order ; and the Russian child,
already referred to, exhibits the same process, in its highest degree, both
the quantity of material and the powers of organisation being sufficient
for the development of a perfect double child.
Dr. Halahan read the following paper on the Mechanism of Labour : —
The position in which the head of the fetus enters and passes through
the pelvic cavity during labour, has long occupied the attention of many
midwifery practitioners, and given rise to a great deal of discussion.
But I am convinced every practical man must allow that the description
given by Naegele, is the accurate, and also the only correct one ; and
that the practitioner cannot, with any degree of truth, contradict the
statement that the head, at the full term of gestation, enters the pelvis in
the four positions described by him. I shall here briefly enumerate them,
the first has the anterior fontanelle directed to the right sacro-iliac
synchondrosis, and the posterior one towards the left foramen ovale ;
the second, is where the anterior fontanelle is, to the left sacro-iliac
synchondrosis, the posterior one to the right acetabulum ; the third is the
reverse of the first, and the fourth of the second.
I am equally certain that those who pursue the study further, will
agree with me in saying, that although the head enters the brini in the
before-named four positions, yet, at the commencement of labour, when
the os uteri is barely beginning its dilatation, the anterior fontanelle is
o 2
' j of the Dublin ( >
always directed towards either acetabulum or] ting in the third
fourth positions I \ . ale. That the fourth changes, at the beginning
of labour, into the DTttj and the third does QOt ch into the MOOfld
Until the head is distending the perineum ; that this is the general I
any other being an exception.
That to diagnose the position in the first Stage <>t' labour, is one of the
difficulties that the accoucheur has to overcome, I am fully aware of.
Nothing but constant attention, very extensive practi therwitha
delicate touch, will, with any degree of certainty, conquer the obstacles,
and make him master of this part of his profession; for, although in
theory it seems very easy indeed to be able to diagnose positions, Of to
which fontanelle presents at either acetabulum, we find, in practice,
it is one of the most difficult points to be perfectly satisfied about)
particularly when the head is high up, the membranes entire, and the os
uteri not more dilated than to the circumference of a shilling.
If, then, it is a fact that at the commencement of labour the fa
always directed towards the pubes, (and I have taken the greatest c
and trouble to be perfectly certain, and have fully satisfied myself that it
is so, not by the mere examination of a few ordinary cases, but by the
most careful and constant investigation of some thousands of patients
which I had the opportunity of watching from the commencement of
labour until the completion of the second stage), there arises the question,
how is it we so seldom find the head in the fourth position when entering
the brim, or even in that position when the 08 uteri is half dilated, but
on the contrary, generally discover it in the first ? Whereas, in the
third, it is the exception for the change to the second to take place until
at the termination of the second stage. The simple answer is, that when
the posterior fontanelle is on a lower level than the anterior, the change
takes place immediately after the accession of labour, or, in other words,
when the chin becomes depressed on the chest, or flexion of the head
occurs early, which is the case in the presentation of the head in the
fourth position. But in the third, we generally find the anterior one a
little lower, or on a level with the posterior, the head being neither flexed
nor extended, which prevents the change taking place until the posterior
one becomes the lower. This seemingly slight difference in the two
makes a very great one in the effect of the uterine action in its efforts to
expel the head, and make the change which I shall now try briefly to
explain.
I presume all will allow that the pain or force of the uterus takes its
course in the axis of the pelvis, and that the entire power may be
directed effectually, and with as little loss as possible, it is necessary
that the occiput should move in the same axis. This is the case in the
first and second positions of Naegele; consequently, if the head enters
the brim in either of these positions, we should expect that labour will
Reports of the Dublin Obstetrical Society. 469
proceed favouraiily. If ant examine a patienl at the commencement of
labour and find tin- head presenting in the fourth position, i lie posterior
fontanelle will generally be the lower or mosl easily reached by the
finger, the anterior one being very high up, and felt with difficulty.
This admits of the uterine force having full power on the head, and the
change taking place at once. Bui when the anterior fontanelle is on a
level with, or a little lower than the posterior one, the greater pari of the
uterine force is lost, being divided between the occiput and sinciput.
This can only be understood by remembering the direction the uterine
force takes, as well as the part of the head it has most power on, as we
will there see that when the forehead is the lower part, the pain has not
its full effect on the head, but that there is a loss of power. This is the
case in the third position, which I think clearly shows the reason that
the head enters the pelvis in the second position so rarely. Again, if we
find the anterior fontanelle presenting, in fact, mid way between the
sacrum and pubes, in the third or fourth position, we may naturally
expect that the labour will be rather protracted, and the second stage
very much prolonged, for the head will, with very few exceptions, be
expelled, face to pubes.
It may very reasonably be asked, is there any practical use in
being able to diagnose in what position the child's head is presenting ?
Certainly there is, the greatest. I shall merely mention two instances.
In applying the forceps, we always intend and wish to place the pubic
blade over the ear, which will be felt a little to the right or left of the
pubes. Supposing, then, you have the instrument correctly placed, is it
not of very great importance to know which ear is towards the pubes, as
in the first and third positions, we have the ear in the right half of the
pelvis ; but if, not knowing the head is in the third, we try to rotate as
if it were in the first, we bring it out, face to pubes, which is not so
favourable as if we had changed it into the second position, the occiput
not adapting itself to the hollow of the sacrum in the same manner in
which the face does ? Again, if version is to be performed in a head
presentation, is it not of the utmost importance, to ascertain whether the
feet are lying towards the abdomen or back of the mother, whereby we
may know which hand to use in performing the operation, and this fact
can only be ascertained by an accurate knowledge of the position ?
I have put in a tabular form five hundred cases, in which the head
has entered the pelvis, showing the relative frequency of the four
positions of Naegele, taken indiscriminately from the beginning of this
year. It will be seen that the first position is the most frequent of all,
being Gl per cent.; the third next, being 31*G0 per cent.; the fourth
next, being 6*40 per cent., and the second least of all, being 1 per cent.
That the third changed to the second in every four cases out of five, or
nearly so, the proportion being 79*75 that changed, and 20*25 expelled
TrCft I nnt.ij and < 'it',
to pohee. Hie fourth changed into the firrrt In 84*37 per cent.
continued m it entered the pelTii in 15*62 per ecnt.
mi. asci.i:iaim:d POSITIONS
in 500 1861.
POSITIONS OF NAEG1.I 1..
1st
2nd
Jrd
I'rimary
3rd
to 2nd
Total,
3rd
Portion
4th
Primary
4th
changed
to lot
Total,
4th
Position
Total in 500 cases,
Per centage, .
305
61
5
1
32
6*40
126
25-20
158
31*60
5
1
27
5-40
32
6-40
Of the 158 cases in the 3rd position at the commencement of labour,
126, or 79-75 per cent, changed to the second; and of the 32 cases in
the fourth, 27, or 84*37 per cent, changed to the first in the progress of
the labour.
TRANSACTIONS OF THE COUNTY AND CITY OF CORK
MEDICAL AND SURGICAL SOCIETY.*
(Continued from vol. xxxiii., No. 65, p. 2iO.J
SESSION 1861-1862.
October, 23rd, 1861.
Doctor Popham, President, in the Chair.
Rigidity of the Left Lower Extremity from Anchylosis ; Caries of the bones
of the Ankle Joint. — Dr. Poppiam exhibited the foot and a portion of the
leg of a woman, the foot being extended to such a degree that the toes
were drawn backwards towards the sole, and the nails buried in the flesh,
producing a most distorted appearance. In connexion with this condition
there was a rigid and attenuated state of the whole limb. The history of
the case was as follows : —
Bridget Curran, a shirt maker, about 35 years of age, unmarried, was
admitted into the Cork Union Hospital, under his care, in May, 1858,
suffering from what is popularly termed "a stone bruise." She had
several uncured abscesses of the absorbent glands of the neck, and had
a These Reports are supplied by Dr. W. P. Bernard, Secretary to the Society.
Medical and Surgical Society* 471
batidon, complete aphonia. The bed had become the seat of a small
abscess which healed thoroughly i<> .-ill appearance, but tenderness
continued tO be felt in the ] >art and spread over the dorsum of t lie foot.
\)v. Popham examined the parts earefully and repeatedly, but was unable
to find any obvious cause for the severity <»f the pain, which was more
superficial than deep-seated. Attn- a patient trial of various remedial
agent*, he found that nothing produced any alleviation of the ease, and
that the foot was gradually becoming forcibly and painfully extended,
any attempt to bend it upon the leg giving rise to violent pain, and even
the touch of a sponge could scarcely be borne. Startings of the limb
occurred constantly, and the patient found most relief by sitting up in
bod with the legs hanging down. Without presenting any visible marks
of inflammation, the foot continued to be drawn backwards until it
seemed almost in a right line with the leg, assuming somewhat the
position which a ballet-dancer tries, by great muscular exertion and long
practice, to maintain, when balancing herself upon the toes. At this
period of the case amputation was proposed, but after a careful exami-
nation of the lungs, the existence of tubercle was clearly ascertained,
which necessarily precluded its employment. The limb then began to
waste away, and the knee joint to exhibit similar suffering, terminating
in similar rigidity. The ailment continued slowly to travel upwards
towards the hip, so that eventually the whole extremity became rigid.
There was no sign of abscess or fistulous opening anywhere, but nothing
could equal the attenuation of the limb, it looked dry and shrunken, like
bone covered merely with skin, the other leg which retained, till towards
the close, its natural size, appearing, by contrast, large out of proportion.
She continued in this state nearly three years, the hectic fever and
pain being kept in check by the careful use of opium, but she finally
sunk from the tubercular disease of the lungs, her mind being clear to the
last.
The post-mortem examination of the parts showed the existence of true
anchylosis in the knee and ankle joints, but the hip joint still admitted
some motion. In the ankle joint, the cavity was nearly obliterated, and
the articular extremities were held firmly connected by a tough fibroid
tissue, so that the power of flexing the foot was lost. The foot was
greatly distorted, the concavity of its arch being increased so much,
that when it rested on the great toe and heel, a perpendicular from
the middle point of the chord of the arch upon the foot, measured two
inches. The great toe was twisted down wards and outwards, con-
siderably beyond the line of the other toes, which successively became
less and less curved backwards, the little toe being least so; the nails were
deeply imbedded in the flesh. On examining the adductor and flexor
muscles of the great toe, they appeared in a thickened and tetanic state,
curving it downwards, and increasing the arched form of the foot. Most
[ ~i -
■ iu. ()lh,.r ,.. I i into mere cellular tisane m m
iv ; the undo AchiLli- showed but little alteration.
mining the internal itate of the bones, the lower portion of the
tibia iree found enlarged, end on breaking it across, it exhibit'
dendritic appearance of ■ e bone. Iti eolonr wrae pinkish,
toeUi erere iride and full of ■ ool mrlest tatty iluid, turning the knife
black: the cartilaginous margin a*ai easily separable. The hai
be rut through by the knife; itfl oils were also I
panded and full of the BSinC fluid. The large toe, which was mppof
unsound, was found unaffected. The most careful examination failed to
detect any sinus, in the parts. The lungs ami liver were extensively
diseased.
Dr. Popham remarked, that in the preceding case, one of the chief
ire- wa^ it- glow progress, when compared with the intensity of the
pain and hectic fever, and which he considered partly due to the judicious
ase of opium. For some time the affection of the joints seemed, instead
of accelerating, to check the pulmonary mischief. Another circumstance
which protracted the ease, was, no doubt, the total absence of external
abscess or sinuses. The patient was of a habit of body intensely
ofuloos; for a time, cod liver oil and the preparations of iron seemed
to afford her some benefit, and a favourable change in the pulnion.
texturo was anxiously looked for, such as would render amputation
justifiable, but unfortunately the hope proved delusive.
V \ i mber 13th, 1861.
Du. Popham, President, in the Chair.
Cirrhosis of the Liver. Dr. Willett, exhibited the liver and spleen of
a patient who had died from Cirrhosis of the Liver, and related the
following particulars of the C81
The present case which Dr. Townsend has kindly allowed me to bring
before the Society, has not the fullest details that I could wish, in con-
sequence of the deceased being a foreigner, and incapable of Bpeaking our
lan^ua^e. The same cause prevented me from ascertaining the ante-
cedent circumstances, and his illness before he came under our notice.
William McCarthy, aged 40, was admitted into the Workhouse Hos-
pital, on October 23rd, under the care of Dr. Townsend. On admission,
the skin, generally, presented a brownish yellow colour, like the appearance
of past jaundice. The lungs, on auscultation, seemed normal, as also the
heart sounds, but with respiration there was more or less slight crepitus,
which seemed due to accumulation of water in the air cells, as the crepitus
seemed very tluid, the abdomen was very tumid, from the presence of
fluid, and Dr. Townsend and myself, on palpation, found the spleen much
Medical and Surgical Society. 173
enlarged, extending from the left hypogastric region into the epigastric.
Tlic liver was not bo easily made out, in consequence of the .i_rr»;ii dis-
tension of the abdomen with fluid, and the tightness of the recti and the
other abdominal muscles, which some authors have given, I believe, as
one of the symptom! of disease of the liver.
After admission, the urine was suppressed, and diarrhoea set in, which.
on being Btopped, again the kidneys resumed their function, and then for
some little time, these, secretions became vicarious, one stopping whilM
the other continued. The treatment was directed to support the patient,
who was extremely weak, and also to get rid of the fluid by the secretion- ;
but he gradually sank under its accumulation, and general prostration.
The veins on the outside of the abdominal walls were much enlarged,
and kept up a communication with the lower extremities, by means of
the epigastric veins, thus indicating some internal obstruction to the
circulation.
Post-mortem. — The lungs nearly normal, excepting some few old pleuritic
adhesions ; the abdominal cavity very full of fluid ; the peritoneum
looking flabby and soft, from its being soaked in the liquid contained in
it ; the kidneys large and congested with blood ; the spleen very turgid
and increased in vascularity ; and the liver much contracted, and having
adhesions on all sides so as to render it difficult of removal ; the peritoneal
coat much thickened, showing that inflammation had thus increased it ;
the gall bladder hanging very loosely from the lower part of the liver,
and the bile all absorbed ; the lower surface of the liver full of small
indurated masses attached by narrow peduncles, and showing here, as
well as over its entire surface, the effects of inflammation, (I may be
allowed to surmise that it is greater at the lower part, in consequence of
the products of inflammation gravitating to the most dependent points) ;
the omentum nearly gone, and of a blackish colour, either absorbed from
the pressure of the fluid to which it was subjected, or taken up for
nourishment as fat into the system.
The spleen was very much increased in size, which, I think, was due
to the portal system being obstructed, and serving merely as a safety
valve to the impeded circulation through the liver, until it should find its
way through collateral circulation, therefore not a disease of itself, but
only one of the sequences of the diseased liver.
I find that inflammation of the liver is divided into that affecting the
substance of the organ, and that of the capsule. The former affection is
a rare one in temperate climates ; that of the capsule extremely common.
Drs. Bright and Budd, prove that in the early stage of cirrhosis, the liver
is enlarged, ami this depends on the effusion of scrum, and lymph, into
its textures, as the result of inflammation, the cirrhotic state arising from
a .-ubacute inflammation being set up in the Glissonian sheaths. The
remote cause of cirrhosis, Dr. Budd says, is certainly, in many cases, the
ty and < 'ito of < <ork
habit oi spirit drinking. The alcohol absorbed into the portal bio
panes through the liver, and *ary probably excit action on in
aes, the Bpirit acting parhapi at A local irritant hayii affinity
the liver than for other o] bown by the fact, that in anin
poisoned by it, at death, nearly all Can he distilled from thj ... But
another can iven, viz., that the blood is changed into what Rokit-
ansky calls the fibrinous cium>. Obstructive cordiac disease al iveU
as a cause, but as only a predisposing one. Congestion favouri the
occurence of both inflammation and degeneration, so that both the h
disease — that is, constriction of the mitral orifice, and cirrhotic change
in the liver, are often, I think, common results of the same condition of
blood to which I have alluded. Many other causes are given besides
alcohol, viz., such as increase the quantity and alter the quality of the
fibrin of the blood.
Several useful questions suggest themselves in this case, viz.: can we
detect the first stage of cirrhosis, that is, when the products of inflam-
mation are thrown out ? Whether wre shall consider it as hepatitis, acute,
or chronic, considering that Glisson's capsule enters into one-third of part
of the organ, (the bile cells only excluded) or, an inflammation special to
the Glisson's capsule. The signs and treatment of such inflammation ; and
lastly, if we can remove the products of this inflammation by absorbents,
iodide of potassium, mercury, &c. ; or whether, as in inflammation of the
pleura and peritoneum, they become, in time, as parts of the body, re-
ceiving vessels from the same source, and therefore soon incapable of
such absorption, and only shrinking by age, but never entirely dispersed,
if not removed during the inflammatory stage.
On the Treatment of Psora in Military Hospitals. By T. W. Belcher,
3M.A. and M.B., Oxon. and Dublin ; L.K. and Q.C.P., Ireland ; Physician
Extraordinary to Cork Fever Hospital, &c.
There are few diseases which the physician is called on to cure, so
disagreeable as psora ; not indeed in its consequences, but in several of its
accidents.
Whilst sulphur ointment reigned supreme, the soldier who had the
misfortune to contract it, more nearly resembled the outcast leper of
sacred history, than any other diseased mortal in these countries.
If he was not compelled to cry "unclean, unclean," to all his neighbours,
it was unmistakably done for him ; and plastered all over with greasy
sulphur, his confinement "sine cloake, sine shirt, sine britches" (like
that of the dead Lord Mayor of Londona) was only relieved by copious
libations of haustus sennre, ever and anon recurring with the regularity
of drums and fifes at roll call and reveille.
* Pettigrew's Chronicles of the Tombs, p. 474.
Medical and Surgical Society. 17.")
I >ut at length an ingenious writer in BrakhwaUe*e Retrospect ><f
Medicine and Surgery^ (vol* 84, p. 20G) propounded 1 1 1 c new theory,
that psora could be cured in half an hour, without either sulphur ointment
or black draught.
It was tried at Chatham. Ahlershot, and Woolwich, in each place
with perfect success ; thereupon it was recommended for general adoption
and we ran only say, that if each case falling into the medical man's
hands, could be so easily cured as those to which we refer, the profession
— even in this intensely practical age — would speedily regain its ancient
magical renown.
Braithwaite's Retrospect says, "the remedy is prepared by boiling
one part of quick lime with two parts of sublimed sulphur, in ten parts
of water, until the two former are perfectly united. During the boiling,
it must be constantly stirred with a piece of wood, and when the sulphur
and lime have combined, the fluid is to be decanted and kept in a well
stopped bottle. A pint of the liquid is sufficient for the cure of several
cases."
During the training of the militia of this city (of which I have the
honour to be the medical officer,) in the past summer, three men, John
Farrell, Thomas Murphy, and Murtagh M'Carthy, on coming up for drill
were found to be infected with this disease, and were subjected to the
following process, viz. : —
First, a hot bath, then the fluid preparation above described was
diligently rubbed into the skin for more than half an hour. As the fluid
evaporated, a layer of sulphur was laid on the skin, and this was removed
by a second bath, leaving the subjects — for they could hardly be teT>med
patients — completely cured. During the rubbing of the preparation, the
acarus was killed, and although all traces of the scabs were not im-
mediately removed, yet the scabs themselves were.
In Belgium, the treatment is anticipated by rubbing the body for half
an hour with black soap, but the writer in the Retrospect says this is
not necessary, the careful application of the fluid sulphur being the only
essential act.
The compound formed in the preparation referred to, is a penta-
sulphide of calcium and a hypo-sulphite of lime.
Dr. Frazer of Dublin gives the combination and result in the follow-
ing formula :—
3CaO+12S=2CaS5+CaOS202
Medical officers of dispensaries have frequent reasons to complain of
the inveteracy of this disease, when treated by all ordinary remedies, but
(provided a change of clothing could be ensured to the patients) by the
plan here noticed, an immediate cure can be effected.
Albeit, psora is unmentionable, in plain English, to ears polite, yet
physicians have often met with it and found difficulty in treating it
f tlit- ( 'utility and i 'ify of (
amongst what we call "■ thu better nlnnntifi," — here i-, bo easy plan for
.subject and phj >ician.
In the I militia men called oat for training only dnrin
.u the year, it is plain they, by this plan, me rains for their
. , instead of spending all their time in tin- leper house of t!i
mental hospital.
A Case of Dijficult Labour, from Malformation of the Pelvis, complicated
with a Uterine Polypus. L>y "William S. Galium. k, M.D.
Ellen Furlong, 30 years of age, the wife of a soldier, was admitted into
the lying-in ward of the Cork Workhouse Hospital on Thursday, 20th of
September, 18G1, at seven o'clock, p.m., in labour with her first child.
It commenced with a dribbling of the liquor amnii, the dilating pains
recurring about every 20 minutes. She continued in this state until Satur-
day morning, the 28th, when the os uteri became fully dilated, the head
presenting. At 10 o'clock of the evening of the same day I was called
on by the midwife to attend, and as the patient had not emptied her
bladder for some hours previously, I used the catheter, and took away
about a pint of water ; after which, finding, on examination of the parts,
the head so firmly wedged in the pelvis that she could not possibly be
delivered without the use of instruments, I tried to apply the forceps,
both long and short, with all the adroitness I could, but did not succeed ;
so I forthwith wrote a note to Dr. Popham, informing him of the case? — that
I tried, but could not apply the forceps, intimating to him my appre-
hensions, that the patient could not be otherwise delivered than by using
the perforator, and wishing his assistance, which he most kindly and
promptly afforded me.
On his arrival he, with great patience and perseverance, for an hour,
at least, tried to apply both the long and short forceps, but could not
succeed in bringing them to lock, the blade passing on the right side
with ease, but an insuperable impediment existed on the left to its
introduction. As the soft parts were enormously swollen and painful,
and the woman's strength was fast giving way, we were reluctantly com-
pelled, in order to save the mother's life, to desist from all further efforts
to deliver the child by the forceps ; the possibility of its being yet alive,
from the circumstances of the case, seeming very unlikely, we resolved
to reduce the size of the cranium by emptying it of its contents. Doctor
Popham perforated the head without any difficulty ; but we both
experienced great resistance in drawing it forward, owing to its ossified
state, which made it quite unyielding. There existed besides a great dis-
tortion of the pelvis, arising from a very contracted state of the pubic arch,
and a close approximation of the tubera ischii ; there was also a uterine
polypus, about the size of a large pear, rather flattened, which had been
Medical and Surgical Society 477
forced down into the vagina, and which I afterwards detected on intro-
ducing my hand to remove the placenta. After long perseverance,
through tear of using any undue violence, lest the wfl parte might be
injured, wc succeeded in drawing down the cranium. I am almost
inclined to think that wc should have failed in accomplishing this by the
ordinary means, were it not for our having recourse to the duck-bill
craniotomy forceps of Dr. Davis, which, most fortunately for us, Dr.
Popham brought along with other midwifery instruments. After freeing
the cranium, the question then arose, how wc were to liberate the
shoulders, which seemed to us equally difficult from the exceedingly con-
tracted state of the pelvic bones; but we ultimately succeeded in doing
so by great ingenuity in the use of the blunt hook, and thereby most
cautiously drawing them out ; the remainder of the body was brought
out after some little delay, but not without trouble. The placenta was
attached to the fundus uteri, and had to be removed by introducing the
hand, and was further impeded by a strong hour-glass contraction, which
offered considerable resistance.
As much diarrhoea followed the delivery, and her condition was most
precarious, we were obliged to give her a large quantity of wine. When
she rallied somewhat, we administered 50 minims of tincture of opium
in a camphor draught.
Sept. 29th. — The nurse stated that she had some sleep, interrupted by
starts of pain. A smart hemorrhage occurred in the morning, which was
checked by the usual remedies. At present her face seems perfectly
blanched ; the pulse very rapid and fluttering ; some tenderness is felt
on pressing the abdomen ; tongue dry and brown ; the vaginal surface
was swrollen and livid. She was ordered wine freely, and pills every
fourth hour, consisting of a grain and a-half each of calomel and cam-
phor, and one grain of powdered opium in each pill. The vagina to be
syringed with warm water and camphorated spirit in the proportion of
half an ounce to about a pint of water. A turpentine epithem was
ordered for the abdomen.
Sept. 30th. — Since last report she took six pills, containing six grains
of opium, with much relief; tongue dry; pulse 120, feeble; abdominal
tenderness relieved. She was unable to pass water, and the catheter had
to be introduced. Tendency of the soft parts to assume a sloughing
appearance. Gums feeling a little tender. To take the pills every sixth hour.
Oct. 1st. — The soft parts beginning to slough ; she complains of much
pain within the vagina ; and there was a copious foul discharge. Pros-
tration very great; retention of urine continues; the mouth is becoming
sore. Omit the calomel. She was ordered to take a pill of two grains
of camphor and one of opium, made up with aromatic confection, every
M\th hour; to continue her wine, and to get strong beef tea through the
day. A yeast poultice was ordered for the soft parts.
■f' the County and (
Oct. I'lK l. — Borne improvement In the state of the -"it parti. Ord< I
to continue everything.
Oct, 4th. — Same treatment continued Intention of urine i
The nurse reported that portion! of a fleshy substance had come away.
The soft partfl .show a healthy surface. It is nim J to detail tin-
daily state of the case, the improvement being gradual, thou
suffered greatly from exhaustion. The soft parts assumed a clean, healthy
appearance; the retention gave way with a fuddtn gosh of water; and
on examining for the polypus with the linger, we found that it had
sloughed off. On the 10th she was ordered meat, and on the lGth the
wine was changed to porter, and she was directed to take a tonic bitter
of infusion of colomba, with compound spirit of ammonia, and tincture
of cardamoms. As there was a thin purulent discharge of an irritating
nature, a vaginal injection of oak bark decoction was used.
Nov. 5th. — The patient has been up and about for some time ; and as
she expressed a wish to go home to-day, we made a close examination of
the vagina with the speculum, as we dreaded at an early period of the
case, from the pressure on the bladder and the inflammation of the soft
parts, that a urinary fistula might occur. We found, with much satisfac-
tion, that the entire vagina was quite healthy, except a very slight ulcera-
tion, not yet quite healed, near the external labia. The os uteri was a little
patulous, but no trace of the polypus existed. We had thus the satis-
faction of sending this poor woman home without having sustained any
injury whatever from her severe sufferings, and, except a remarkable
degree of paleness, showing all the appearance of returning health and
strength.
I would draw attention particularly to the free use of opium in this
case ; it appeared both to allay pain and keep down inflammation.
Though taking, at one period, six grains of opium a-day, she showed
none of the untoward effects of the medicine. It was evident that the
retention of urine must have been caused by the pressure of the polypus
upon the urinary organs, as, upon the sloughing away of that body, a
gush of urine took place, and the retention totally disappeared.
Dr. Willett exhibited a pathological specimen, and related the
following particulars of the case.
Michael Mehegan has been 13 years in the workhouse and hospital ;
having generally suffered from bad health, which seemed due to his
possessing the scrofulous diathesis. Four years since he was attacked
with paralysis in the right leg, which prevented his moving about in the
usual wray, and thus necessitated his lying more or less in bed. Still
later, two years since, he had an attack of hematuria, which lasted for
three weeks, but gave way to the treatment ordered by Dr. Townsend.
From that time till the present he enjoyed his usual health.
Medical and Surgical Society. 479
On October 29th, '61, he bid a second attack of hematuria, which
continued till his death. He usually patted ahmit five pints of urine per
diem, coloured with blood, bat only in ft very small stream, and at. last
only guttatim. There were no calacli voided with the urine, bat some-
times b thick substance which gravitated to the bottom of the vessel,
which, from the port mortem appearance, very likely contained pas globules.
He complained of acute pain over the region of the bladder when the
hand was placed there, hut had not the slightest pain when pressure was
made over the lumbar or renal region.
On October 7th he was ordered stupes of turpentine, with gallic acid
and Dover's powder, of each 10 grains, three times in the day (urine
continuing as before) ; and pain, on pressure, still in the region of the
bladder.
November 7th. — The pain continuing, was dry-cupped over the renal
region, and ordered half a drachm of tincture of opium three times a day,
with two bottles of soda water, and the gallic acid also continued, which
treatment he used till his death, on November 14th ; the amount of blood
Still continuing, and the pain over the bladder, though less than before,
still felt on pressure. The only symptom showing that the disease was
in the kidney was, that the blood was intimately mixed with the urine,
and not coming away with the last drops, as it would do if from the
bladder, and at the same time would not have been so thoroughly in
solution.
Post-mortem and pathological appearances. — The viscera below the
diaphragm healthy, with the exception of the kidneys. That on the
right side being so much attached as to render its removal difficult. Its
structure was much disorganised, and its bulk greatly increased and
overlaid with adipose matter. That on the soft side was very large, and
containing three sharp-pointed calculi, which I have, by tests, found to
be oxalate of lime, with organic matter. Their size and shape must
have produced great irritation to the kidney. They could hardly have
been extracted, I think, by the ureter. The bladder was much dis-
organised by chronic cystitis; and at the right superior angle an ulcerated
opening was seen, which would account for the great pain on pressure in
the pubic region. The prostate gland was not much enlarged though the
common opening of the vesicula seminalis, and vas deferens was very
much increased in size. The ulceration in the angle of the bladder did
not penetrate the peritoneal coat ; and it was only in removing it that
the urine escaped from the opening.
Dr. Finn exhibited a mulberry calculus about the size of a kidney
bean.
The subject of this case was a female in an advanced state of preg-
nancy, who was brought to the Lying-in Hospital, suffering from pains
<tjj and ( '<t<j of ( 'ark
which \wiv supposed i I with parturiti-.n. On mi
tlcului was observed to protrude from the orifl !
the urethra. On its removal the pains immediately subsidi
Decemki.i: 1 1 tli, 1861,
Dli. POPHAX, President, in the Chair.
Observations on some C<> D t. B Y Dknis ChABLBS OH
A.B., M.B., T.C.D., Professor of Practice of Physic, Queen's ('.,11.
Haying recently been culled on to treat BOOM Casefl of diphtheria, and
having heard that eases als(» presented themselves in the practice of other
physicians in this locality, I thought it might be useful to bring the
subject under the notice of the society, that we might not be unprepared,
if this fearful malady should appear amongst us in an epidemic form.
On former occasions, we had opportunities of observing the evils which
resulted, when physicians were unacquainted with an epidemic at its
first outbreak, as in the case of scorbutus or land scurvy, which existed
for a long time before it was recognised by many physicians otherwise
well informed, and who, consequently, could not apply the proper remedy,
though so obvious, effectual, and of such easy application.
Every physician of much experience, has met with cases bearing a
resemblance to diphtheria in its local characters, for instance, in malignant
scarlatina, in some cases of typhoid fever, and in idiopathic pharyngitis.
But these affections, though sufficiently dangerous, differ from diphtheria
in some striking characteristics, first, in seldom, if ever, invading the
larynx and trachea, though the intlammation is in such close proximity,
whereas, in diphtheria, this constitutes its principal danger; secondly, in
the great debility and prostration of strength, and occasional muscular
paralysis in diphtheria, which are out of all proportion to the local in-
tlammation, showing they do not exist to each other in the relation of
cause and effect.
This disease was first described by Bretoneau, of Tours. He describes
it as first affecting the tonsils, then spreading along the pharynx, and
ultimately reaching the larynx, where it produced a disease identical with
croup, with which it was confounded. He makes no account of the fever
which accompanies it, nor its peculiar tendencies, and appears to look on
diphtheria as altogether a local affection, which, if once checked, the
entire disease would be removed. Recent observations of the disease, in
England, has led to a different conclusion, or perhaps the disease assumed
different types, at the two periods referred to. In the latter period, the
croupy state of the larynx appears to be by no means so frequently
observed, and many cases have succumbed, without any local disease to
account for the death of the patient, the result manifestly depending on
Medical an<l Smuiiral Socief//. 1*1
i specific poison of the nervous system, The extreme debility, which
appears to be the essentia] character of the disease, is shown, even in
wry mild cases, l>y weakness of the limbs; a tottering gait; temporary
loss of vision; tinnitus aorium; difficulty of deglutition, and a nasal
t<>ne of voice, remaining Long after the local affection has passed away.
These facts, and the conclusions necessarily resulting, are of great im-
portance in directing our attention, as much to the extreme nervous
debility of the patient, as to the local affection of the throat. The
following cases, though few, will serve to illustrate the principal points
referred to in the foregoing remarks.
In October, 18G0, a child, about 12 years of age, arrived from Dublin,
at a boarding school in the neighbourhood of this city. On the following
day, she complained of slight soreness of the throat and some difficulty of
swallowing. It was ascertained, that before leaving Dublin, two of her
sisters were similarly affected, and they were stated to be dangerously ill.
When I saw her, on the third day of her illness, both tonsils were covered
with a coating of lymph, and the whole of the pharynx was of a purplish
red colour. She swrallowed drinks with pain, but could not swallow
solid food. There was little fever, the pulse was somewhat quicker than
natural, but there was scarcely any heat of skin, and there was a peculiar
expression of languor in her features, which were of a pallid hue. Her
voice was nasal, resembling that of a person who had suffered from
ulceration of the palate. After relieving the bowels, with gentle aperient
medicine, I gave decoction of bark, with dilute sulphuric acid, in small
repeated doses ; ordered a gargle, containing a solution of chloride of soda,
and touched the tonsils twice a day with a solution of nitrate of silver,
fifteen grains to the ounce. I directed her to be supported with chicken
broth, wine, and arrow-root, new milk, and barley water. She had much
difficulty in swallowing the two former in sufficient quantities, and had,
in a great measure, to depend on milk for her support. After some days
the tonsils became ulcerated, with a fetid smell from the breath. Part
of the fluid which she attempted to swallow, flowed through her nostrils,
and she had constant vomiting. This was arrested by the application
of a blister, to the epigastrium, and a few drops of laudanum. She
subsequently complained of severe pain in the region of the stomach, so
violent, that I suspected the presence of an ulcer in that organ.
When ill about three weeks, the ulcers threw off their sloughy
character, and were beginning to fill up with healthy granulations ; she
was also able to take liquid food with more regularity, still there was
extreme weakness of the pulse, a coldness in the skin, and languor in the
countenance, not easily explained by the local affection. Her intellect
was at all times clear, and she talked freely with her attendants, though
her utterance was not distinct, owing to the paralysed condition of the
VOL. XXXIII., NO 66, N. S. P
ns of ( ' ' 1 1
inn thr palate. While in th. I ap in bed to take a
drink, tell back, as it' in ;i taint, and expi h tli<- peeoll
inflammation of the throat was severer in this case, than in any othe.
diphtheria which I had met, still, her death was attributable, not to t.
cause, but to the poisoning of the nervous system, which, I i .to
be the essential character of the disease. Two or three days after the
arrival of the child, who- 1 have just related, three other childi,
belonging to h . became attacked with nearly the game symptCH
namely, constriction in the throat, difficulty of swallowing, with -li
fever. In all three, the tonsil- were covered with the same Coating
Lymph, and the pharynx more or less inflamed, and of a dark red colour.
In two of these young ladies, the disease ran a rapid course, to a favor-
able termination ; the third was more tedious, still, the local affection was
never so severe as an ordinary case of tonsillitis, or pharyngitis, but th
was languor, debility, loss of appetite, and the peculiar voice to which I
before referred. In about ten days from the commencement of the
attack, this child had apparently recovered. Her throat was quite well,
there was no difficulty in swallowing, still, the voice had not its natural
tone, and there was great muscular debility in the Whole body. When
walking, she occasionally tottered in her gait, and felt a reeling in the
head, wdiich made her unwilling to leave her chair. She complained of
motes flitting before her eyes, and sometimes lost her sight for several
minutes, accompanied with a ringing in her ears of a most distressing
kind. In this case, I examined the state of the urine, which contained
no albumen. The child continued in this distressing state, nearly th]
months, although, during the entire time, her appetite was very good,
and her general appearance showed no signs of delicacy. She finally
recovered perfectly.
These cases clearly establish the contagious character of this disease,
as all of these children, were, more or less, in contact with the young
person first attacked, and no other case appeared subsequently in the
school after their isolation. The last case I have referred to, shows in a
special manner, the predominance of the nerve poisoning over the local
symptons, as the nervous debility lasted long after every other symptom
had disappeared. This should lead us to rely less on the statements of
writers, who trust almost entirely to local applications, for the cure of
this disease.
About the end of last October, I was called to see a child about five
years old, labouring under symptoms nearly similar to those I have
already described. During the first week, there was little to observe but
the inflammation in the tonsils and pharynx, subsequently there was
great debility, pallor of countenance, feeble pulse, and vomiting. At a
later period, diarrhoea supervened, and there appeared but little hope of
the child's recovery. However, by the constant use of stimulants, and
TVansactions oj the Belfast Clinical and Pathological Society. 483
keeping her in the recumbenJ pdstnre^ehe rooorered, after a protracted
con yalesoenoe ; fche leal symptoms which dinapnatrrrri, bring tho pfimlinr
nasal voice.
TRANSACTIONS OF THE BELFAST CLINICAL AND
PATHOLOGICAL SOCIETY.*
NINTH SESSION, 1861-62.
Case of Cataract. — Dr. Browne introduced a young girl, aged 14, from
the country, labouring under cataract in both eyes.
He observed, that the case before the Society presented the usual
appearance of congenital cataract, though the patient, up till two years
ago, had enjoyed good sight ; since that time the powers of vision had
gradually declined, until now she could merely distinguish the outline of
large objects, even when the pupils were fully dilated. No cause what-
ever could be assigned for the occurrence of the disease, as there had
not been any injury or previous affection of the eyes. In his opinion it
was the result of slow inflammation, and the consequent arrest of nutrition,
just as, he believed, occurred in congenital cataract, either in utero or
very soon after birth. Certainly it was very rare, he said, to see cataract
occurring, as this had done, in a perfectly healthy young person, and
where there had not been injury.
The operation he designed was that for breaking up and absorption —
improperly called the operation for solution. He observed, that the
needle — a very fine one — should be introduced through the cornea, and
the capsule of the lens should be only slightly torn in the first operation,
lest inflammation should be set up. In the future operation or operations
the needle could be more freely used with comparative safety. Some
weeks should intervene between the operations ; indeed the needle should
be only used afresh when absorption or the disintegration and disappear-
ance of the cataract seemed at a stand still. — 26th October, 1861.
Dr. Browne exhibited a patient labouring under traumatic cataract.
The capsule had been wounded by a blow from a hackle-pin ; and spon-
taneous cure was now going on by absorption. — 2nd November, 18G1.
Case of Enehondroma of Hand. — Dr. Browne presented the model of a
hand, taken in plaster, and also the morbid specimen which he had
recently amputated for enehondroma.
These reports are supplied by Dr. Wm. M'Cormac and Dr. David Moore, Secre-
taries to the Society.
p2
[ 8 1 Tr /' the I ■
1 • patient was ft woman, ag< i I i -. • tars, from tot country, i
Belfast. She stated, that tome I be had obai - unall
iot€ to tin- bead of the metacarpal bom- of great Anger. Ti
she Bays, was entirely dispersed by treatment. Within the Last t\\"
however, it hud returned, and the iwelling extended rapidly from that
point to the rest of tin- hand, involving tin- metacarpal bonei and tin-
phalanges, with the exception of the distal phalanges of tin- thumb and
little tinger. The principal enlargement was on the hack of the hand,
where the tumour presented a somewhat unequal, glistening surface, the
veins at some parts being tortuous, full, and enlarged. This tumour v
elastic; and, at one or two place-, there was a sensation of fluid beneath
the touch. She came into hospital on the 4th; and on the 10th of Sep-
tember the hand was amputated three inches above tin- wrist joint, by the
double flap of the integument and circular of the muscular structure.
The stump, an excellent one, healed up kindly. Six weeks after the
operation he saw the patient in excellent health. Indeed her health had
not suffered much before, as she had not had very much pain — only
neuralgic uneasiness arising from pressure upon the nerves.
On making a section of the tumour, and dissecting back the integu-
ments, there was a very thin shell of soft bony structure, then cartilaginous
structure containing gelatinous matter in cells. This portion very closely
resembled boiled sago mixed with red wine. The entire normal struc-
tures of the entire hand had been destroyed. The metacarpal bones of
the thumb and little tinger were flattened, and changing into cartilage,
the osseous structure having nearly disappeared.
Though the ago of the patient, the rapidity of the growth, and resem-
blance of some parts of the mass to colloid cancer, might raise a doubt as
to the true nature of the growth, he still thought the case one of en-
chondroma, rapidly degenerating — doubtless a rare affection, and not one
of malignant disease. — 9th November, 1861.
Fracture of Clavicle. — Professor Gordon exhibited a patient who had
sustained a fracture of the clavicle at the junction of the outer with the
two inner thirds. The outer fragment had undergone the usual dis-
placement, inwards and downwards. He has maintained, for some time
past, that in fracture of the clavicle the shoulder is elevated, instead of
being depressed. In the treatment of this accident he does not push the
shoulder upwards and backwards, as usually recommended, but depresses
it. He places a very large pad over the lower part of the side of the
thorax ; along the arm and forearm an angular splint, well padded above,
where it rests against the biceps muscle, and extending from the anterior
border of the axilla to the hand. The lower part of arm and inner surface
of elbow is then firmly bandaged to the large pad. The elbow joint
being thus fixed, and rendered incapable of flexion by the splint, he next
Clinical and Vathohxjical Society . 485
elevates tin- forearm at tin- wrist, by a filing, which passed round i he neck;
and by bo doing the shoulder is depressed and pushed outwards; In the
present ease this apparatus has suooei «1im1 admirably in maintaining
accurate apposition <>t* the Fragments. It is simple in construction, easily
applied, and uo1 liable to become disarranged. — 23rd November, 1801.
PnOFESSOB Gordon introduced a patient whom he was treating for
comminuted fracture of the clavicle., — 23rd November, 1801.
The President then read his opening address, which had been deferred
until this date owing to his unavoidable absence.11
Compound Comminuted Fracture of the Tibia and Fibula of the Right Leg. —
Dr. Browne read the following case : —
George Mayers, aged 18 years, a strong healthy young man, was
admitted to the General Hospital on the 18th of October; three hours
before, the wheel of a baker's heavy cart had passed over the right
leg, about four inches above the ankle. Both bones were broken. At
the posterior part of the leg a wound existed about an inch in length ;
but the bones did not protrude from this, though the bruised tissues did.
The limb was put, upon the outside, in a padded splint, and flexed at the
knee, and the wound covered by water dressing. Erysipelatous inflam-
mation, with considerable serous infiltration, soon set in, and extended to
the knee ; and in a week after admission the integuments on the front
part, over which the cart-wheel had passed, as well as the posterior
wound, had sloughed, exposing the broken ends of the tibia, denuded of
periosteum for about three-fourths of an inch. Various contrivances
were adopted to keep, or rather to bring, the fractured ends in apposition ;
but this could not be accomplished. At this time the constitutional dis-
turbance became great, and the suppuration copious ; still it was deter-
mined to give him a chance of saving the limb. Stimulants and tonics
were freely exhibited ; and, for some days, considerable improvement
took place. However, the sores soon after assumed a very sloughy, in
fact phagedenic appearance, the constitutional irritation increased, and
there was great infiltration of the entire limb up to the groin, with pain
along the course of the saphena and femoral veins, upon pressure. At
that time the fractured parts of tibia were exposed for an inch above and
below, and a large slough had taken place in the back part of the limb,
behind the seat of fracture. Under these circumstances, though the issue
seemed very doubtful, it was evident that amputation must be resorted to,
to save life, if possible. Tlie operation was accordingly performed by me,
on the 14th instant, by the double flap of the integuments and circular
* Printed among the Original Communications in our present number. — See p. 281.
incision through the soft porta, the b <-ut through three in
w the tubercle of the tibia. Thro and the -tump,
put up four houri after, with straps of wet lint. I
oui infiltration of the limb, to which reference hai bees made, the
is were found to be greatly inflamed and blocked ap by ■ elot Be
had had, moreover, on two occasions, bcti <n — one a week, and
another three days, before the operation.
The opium ami quinine, irith six ounces <<f nine, i Ac., which
he had been taking, were ordered t<> be continued. On the 18th tin-
wouml was opened far tin- first time. The -tump did n«»t -how the
smallest Bign of any healing by the Brsl intenticn ; hut, otherwise, did not
k unhealthy. The infiltration of the limb had greatly subsided; ami
the pain, on pressure along the veins, was not >>> great a- before. Opiated
mercurial ointment was directed to be rubbed along the course of the
inflamed veins, ami the .stimulants, opium, &c, to be continued. On the
BlZth day after the operation, he had a sharp rigor, which caused some
apprehension. On the eighth, pretty free suppuration of the stump had
taken place, and there had not been any return of the rigor. On the
tenth, the last ligature came way, and the patient seemed improving. On
the twelfth day after the operation, however, he had, in the course of
nine hours, three severe rigors, followed by profuse sweating. On the
thirteenth day, an increased discharge of pus occurred ; and there was
not any recurrence of the alarming symptoms which caused the dread of
pyemia ; and he was discharged, four weeks after the operation, with a
good stump, and with completely restored health, which had been so much
shaken by the results of his unfortunate accident. On the whole the case
i- interesting, as showing that young persons will survive operations
frequently, even when performed under the most unpromising conditions.
The bones of the parts at the seat of fracture were found to have been
greatly comminuted, stripped of periosteum, and, in fact, in such a state
as to have afforded no chance of repair. — SOth November, 1861.
Case of Disease of Hand, requiring Amputation. — Dr. Browne showed the
morbid parts, and gave the following statement of the case: —
Peter McCaffrey, aged 54, previously of excellent health, and of tem-
perate habits, was admitted into the hospital — first, in September, 1857,
having had the middle finger of his left hand crushed between rollers, so
much so that amputation of the part was performed by Dr. Browne,
through the first phalanx. In five weeks he was then discharged, with
the part quite healed up ; and he remained well till the month of August
of the present year, when he sustained a kick from a horse on the old
cicatrix, which broke up the remaining portion of the first phalanx, and
drove the splinters into the palm of the hand. He wras admitted into
Clinical and Pathological Society. 487
hospital, wlim Dp. Murney removed tin* fractured portions of the bona,
and took away the former stamp at the metacarpophalangeal artionlatioi] ;
the parts healed up, and he went out qnite well at tie- end of a month.
On the L2th <>f October he returned with the eie;ilii\ completely opened,
and presenting a most unhealthy phagedenic character, with rtinnasfl of
the metacarpal hone. Kxten.Mve sloughs, harrowing beneutli the palmar
fascia, took place, frith great enlargement of the wound; in fact the
gangrenous state progressed, despite all treatment, till hemorrhage took
place which could not be controlled, and rapidly reduced the strength of
tin1 patient; this, combined with the excessive pain of the part, was
quickly wearing the patient out, so that it seemed amputation was the
only resource left, and for which the patient was most solicitous. Dr.
Browne, therefore, amputated, a little above the wrist, on the 16th of
November. The stump healed up quickly, and the patient regained his
health and strength — the only retarding circumstance to his rapid con-
valescence having been suppuration of the glands in the axilla. — 30th
November, 1861.
Compound Comminuted Fracture; Amputation. — Dr. Browne exhibited a
limb which he had to amputate the preceding week, in consequence of
being completely smashed by a railway waggon wrhich had passed over it.
The operation wras performed through the lower third of femur, by the
double flap of integument, and circular incision of muscles — care being
taken to make the anterior flap long. The stump promises to be an
excellent one. — 30^/i November, 1861.
Professor Gordon introduced a patient who had sustained an im-
pacted fracture of the surgical neck of the humerus, together with frac-
ture of the radius of the same limb. At the same meeting Professor
Gordon showed an arm wdiich he had found necessary to amputate for
compound fracture at the elbow joint. — 30th November, 1861.
Epiulis. — Professor Gordon exhibited a specimen of fibrous epulis,
and gave the following details : —
Ann Dyer, admitted into hospital November 9, 1861, aged 18, com-
plexion florid, and her general health very good. About five years ago
a small tumour appeared in the gum, opposite the second incisor tooth of
the right side. At first this tumour grew very slowly, being at the end
of three years scarcely half its present size. On admission into hospital
the right side of lowrer jaw presents a firm oblong tumour, extending from
the first incisor to the second molar tooth ; it is almost an inch in length,
and fully three-fourths of an inch in depth, rising upwards almost to the
level of the upper margin of the crown of the canine tooth ; it is not
painful on pressure ; in colour a little whiter than the gum ; firm, and
/ '/•■.
iU surface perceptibly a numi tall
protuberan Around it- margin i* overlap! closely the neighbour
gun und teeth; the first molar tooth is directed more inwards than that
of the opposite; but thi> seems due rather to crowding of the teeth than
lisplacement by the tumour, ai none of them arc in tin* alight
degree loose. There ii increased vascularity beneath the mncooa mem-
brane, at it.s reflection apon the lip, immediately below the tumour.
On attempting to remove the tumour with the scalp <- substance
- encountered. The scalpel was, therefore, laid aside, and the cutting
forceps applied, one blade above and the other below the tumour. The
IMSJ Was thus easily and perfectly detached; and were I called upon to
perform again a similar operation 1 would use the cutting forceps. The
fang of the canine tooth was denuded almost to its point, and an osseous
spicule, about one-eighth of an inch in diameter, divided. ThN spicule
projected fully one-fourth of an inch into tin- tumour.
Although the alveolus between the canine and second incisor tooth
seemed sound, yet, from the recognised tendency of such tumours to
repullulate, the incisor and canine teeth were extracted, the intervening
alveolus removed, and the surface touched, lightly, with potassa fusa. On
examination of the tumour, after removal, we find it firm, slightly elastic,
colour white ; its surface perceptibly uneven, with a fibrous section, pre-
senting a groove corresponding to the fang of the canine tooth; and that
its point of attachment was much less than would have been supposed from
the external examination. A\ 'lien cut into, a small cavity was exposed,
filled with sebaceous-like matter, which, when examined by the microscope,
is found to consist of plates of cholesterine, oil globules, granular matter,
and a few epithelial scales. The tumour itself seems, on section, to be
decidedly fibrous, yet the microscope shows it to belong rather to the
fibroid than fibrous tumours. The Beveral cavities containing sebaceous-
like matter are, I think, the follicles of the gum distended by a secretion
which has undergone degeneration. If we give to this fact its due weight
I think it will lead US to infer that the tumour involves, and has its origin,
simultaneously in the gum, periosteum, and alveolus. — SOth November, 18G1.
Disease of Femur. — Dr. BBOWNE exhibited a patient labouring under
disease of the left femur, and made the following statements regarding
the case : —
The lad, nowT eight years of age, had, till four months since, excellent
health, and is descended from healthy parents, not related by blood. At
the time referred to he had a fall upon the hi}), but which neither caused
fracture nor luxation ; indeed he continued to walk for a week after the
fall without suffering pain, and without lameness. He then began to keep
his bed, and suffered, for several weeks, great pain, with much swelling
around the hip, and of the thigh also. The medical practitioner who
Clinical and Pathological Society, l*fJ
saw the case in the country. Supposed that suppuration WM about to take
place. By degrees the pain subsided, and the swelling diminished; but
then, for the first time, some five weeks' since, great shortening of the
limb was observed to have ensued. When the boy was broaght to the
hospital, on the 1th instant, In- (Dr. Browne) diagnosed spontaneous
luxation at hip joint, with disease of the shaft of the femur. He said he
Was Led to believe, from the history of the case, that acute liip-joint
disease had resulted from the tall; that dislocation ensued, after some
Weeks of destructive inflammation: and th.it the disease of the shaft of
femur had occurred about the same time.
The present condition of the patient, he said, is obvious. The femur is
displaced upwards ; the head and neck partially absorbed, are resting on,
and nearly fixed to the dorsum of the ilium ; the shortening amounting to
fully three inches ; the shaft of femur and soft parts are greatly enlarged,
and the integuments have large veins ramifying extensively through them.
The patient's health is good ; and there is not the smallest pain on pres-
sure, or on attempting motion of the hip. Still, even with these negative
signs, he could only arrive at the conclusion that cerebriform disease of
the femur is present, and that it would eventually prove fatal. The pro-
gress of the morbid growth had not lately been rapid ; but the members
of the society were well aware that in many of these cases the disease, for
some time, seemed almost stationary, when all at once it advanced with
great speed ; and finally, having burst through the integuments, it soon
destroyed the life of the patient, either by the constitutional irritation set
up, or, in some instances, by the exhaustive drain of repeated hemorrhages.
He concluded by stating he would keep the patient in hospital for
some time, would watch the progress of the disease narrowly, and would
report the issue to the Society. — 1th December, 1861.
Extroversion of Bladder, §-c. — Dr. Browne introduced a lad of 14 years
of age, who had congenital absence of the anterior walls of the lower part
of abdomen and bladder ; the back part of the bladder projected forward,
and exhibited the mucous surface to the extent of about an inch and
half square, with the ureters opening at the lower portion. Beneath this
the rudiment of a penis appeared, the corpora cavernosa separated
above, with a small opening in the sulcus, between the bladder and back
of penis, seemingly the mouth of the common seminal ducts. The testicles
were fully developed and enclosed in the scrotum, which approached to
the normal condition beneath, but separated above, passing to each
ascending ramus of the pubis, the two portions being united by a thin
integument and membranous band. The pubes were separated at the
symphysis, the interval being filled by strong ligamentous structure. There
was no trace of a urethra, except what has been referred to as the openings
of the ejaculatory ducts. — 7th December, 1861.
1 >i.r,( )i i , n Restoration of I /
Ex . ".ills. — l>m BbOWWI i ii i !■ « 1 1 1<-
from whom he bad excised greatly enlarged t ind
exhibited the hypertrophied parts.
This young girl was of small growth, and not at all de\» I cording
to her . She had suffered, for several \»-ar«, from repeated attacks
of inflammatory sore throat; and latterly the enlargement of the ton
had become so great ai to interfere materially with deglutition, speech,
and breathing ; and her general health had Buffered aUo. The eatainenia
had never been properly established, and the mamma- were undeveloped.
Dr. Browne regarded the operation of removal as established in sneh
cases; and his experience of many cases was, that within one year ai
the excision of the hypertrophied tonsils, in young females, the system
became fully developed, and the health quite re-established* lie con-
sidered the operation quite safe, provided the surgeon took care not to
cut too deep, or outwards; but having drawn the tonsils towards the
mesial line, he carried the knife — probe-pointed — with its edge directed
forwards, and its flat pressing against the arches of palate, completely
through the enlarged mass. Very little hemorrhage had occurred in his
practice, and he had never witnessed any unpleasant results.
With regard to the notion entertained by some authors that removal of
the tonsils would interfere with the sexual reproductive powers, be said,
in the first place, the tonsil- ne\er were, and could not be excised; it v
only the morbid growth or hypertrophied portion that was removed; and in
the second place, he contended that the removal of these morbid growths,
instead of interfering with sexual development, actually had the very
opposite effect, lie concluded by saying that he strongly recommended
the operation in all suitable cases — such, in fact, as the oue be had intro-
duced to the notice of the society. — 1th December, 1861.
On the Restoration of Congenital Fissure affecting the Hard and Soft Palates,
icith a comparison of the resources indiridually offered by Prothesis and
Autoplasty. A letter addressed to Professor Lawrence, by Doctor
Dehout.
Dear Sir, — It was not permitted your illustrious friend, M. Roux, to
complete the work in which he proposed to make us acquainted with all
be had seen or done of notable utility during his long professional career.
But he had at least the consolation of terminating that portion in which
he took the greatest interest on account of the large share he took in its
elucidation, and which we have termed restorative surgery.
I shall not here examine whether our skilful surgeon has not omitted,
in spite of the large space allotted to this subject, the consideration of
affecting the //<>/</ and Soft Palates. -UM
some <>f the affections naturally allied t<» it. He baa himself taken care
to obviate any reproach upon this account, by informing us that be writes
more t<> demonstrate the really valuable assistance offered by th<
applicationa of restorative surgery which be has attempted with the most
surer--, than to compile a complete treatise upon the subject.
And thus, in Blinding t<> vesieo-vaL'inal li-tnla. in the treatment of
which restorative Surgery lias given such brilliant results in the hands of
M. Jobert, M. Roux, not taking sufficiently into account the experience
of others, says, "There are other restorations of too recent B date, and so
lately instituted, as not to allow of their having been performed a
sufficient number of times to enable us to pronounce upon their proper
value, or to appreciate the especial worth of the different processes of
which each is capable."
But we may justly criticise our illustrious master as to his voluntary
silence regarding the value of such prothetic apparatus as industry, alone
and unassisted, has succeeded in creating, to remedy deformities which
even his skilful hand had failed to remove. Restorative surgery being,
according to the definition of M. Roux himself, that part of our art
especially destined to restore deformed organs, or those having suffered a
loss of substance more or less considerable, to such a condition as will
enable them to accomplish their natural functions ; our art would often
fail, to bring about this result, were we to omit the study of the real
resources offered to us by prothesis.
For example, when the mutilation is confined simply to the soft parts,
and the loss of substance is not too considerable, we are able, by ingenious
processes, to render an increased mobility to the neighbouring parts and
thus bring them into contact. It is no longer the same when the loss of
substance affects the bony structures ; here coaptation is no longer possible,
and synthesis must give way to prothesis. Synthesis and prothesis are
but portions of the same whole, and has not M. Roux, in consecrating an
entire volume of his work to restorative surgery, and still confining
himself to the consideration of synthesis alone, been guilty of a serious
omission ? It is a doubt which I beg your permission to express.
For some considerable time we have lost no opportunity of impressing
upon surgeons the loss accruing to science, from their abandonment of all
study of mechanical apparatus to instrument makers and the patients
requiring them, and we wish to continue our task.
Operative surgery must at length learn to take into account the
resources offered by prothesis. According as this latter becomes capable of
repairing greater mutilations, the operative surgeon will become more
enterprising. But a few years back would any surgeon have dreamt of
removing the two superior maxilke.
But at the same time that the operator may, in the present day, become
more daring, owing to the abundant means now offered for filling up the
Dxboi l Ml 1 '
tehee thai be mas i bis patient*, be ought also to
[ye place to proth< n as fcbia latter has attained
sufficient d< i accomplish the end in rii
irding prothetic apparatus, their trial is in all inoffenaj
this is far from the case in respect to the applications of autoplasty, which,
iV the least, in I non-success, leave the loss of sud iter
than before.
Therefore, would it not be wiser to commence by ■ trial of these means,
in all cases where their success is probable or even possible, instead
recurring as a last resource when we nave already rendered it- ta>k m
difficult? Such is the question which I desire to lay before you, as the
person whose Long experience has most fitted, to give us a solution.
I have chosen for my subject the restoration necessitated in the buccal
cavity by the congenital fissure of the palate, implicating both hard and
soft structure-.
II Roux, in his Conservative Surgery^ has shown what resources are
offered to the Burgeon by operative interference. Allow me in turn to lay
before you the real value of the means that prothesis affords us in the
treatment of these affections,
I have neither the authority nor the talent of demonstration posse -
by our professor; consequently I shall speak by facts, and leave them to
plead the cause which I defend.
I have taken for example the most complicated of these cases, viz., a
M in which the arrest of development affected the lip, the palatine arch,
and the velum pendulum palati, constituting the deformity known with
us as gueule de fotip. I shall thus have occasion to indicate the share
which in restorative surgery falls to the lot of synthesis and prothesis
individually.
Operative surgery, by borrowing the required tissue from the directly
adjoining parts (^'autoplastic par glisseinent), easily succeeds in closing the
labial fissure, and in restoring the nose to its normal form. When this
autoplastic operation is performed during the first months of existence, as
is now most frequently the case, the influence of the simple restoration of
the lip causes the gradual disappearance of the breach in the alveolar
portion of the maxilla.
Such is not the case with the fissure of the bony palate; the palatine
cleft remains unchanged. Nevertheless, were it possible to perform the
operation of staphyloraphy at the same epoch as that for hare-lip, the
union of the soft parts would exercise the same influence npon this fissure
as upon that of the dental arch; the separated portions of the hard
palate would so far approach each other as to leave but a slight
longitudinal fissure which it would be easy to close.
But staphyloraphy is not an operation which can be performed upon
very young subjects. In the words of M. Roux, " That it may be
affecting the Hard and Soft Palates. 493
performed with precision and employed with success, the patient must
possess n Btrong will and a firm resolution, he must have the sentiment of
his infirmity and a lively desire !<> gel <|iiif of it ; lie nniM lie possessed of
the courage necessary t" affront the pain; and he capable <>i presiding
over himself during the after treatment ; he must also have sufficient force
of character and patience to endure certain privations necessary to
ensure Bucoess.
"Nothing can be commenced, pursued, or terminated, without his con-
currence, without his will, without his participation. The degree of
reason and the force of character possessed by a person of from 18 to 20
years of aj^e is no more than is necessary ; but it is sufficient ; and we ought
to profit by this the first favourable moment, in order to afford as soon as
possible, to such as suffer from the errors of nature the benefits which art
may be able to procure them. Waiting a few years later would only give
perchance to our patients a greater resignation and a more firm courage,
without placing them in other respects under more favourable circum-
stances." We have preferred giving the words of M. Roux, himself, in
order that we might not be taxed with having, in the interest of our cause,
retarded the epoch favourable to the intervention of our art; and
exaggerated the moral qualities necessary in a patient who would undergo
the operation of staphyloraphy with a prospect of success.
It is unnecessary to describe the operative processes of M. Roux, for
the restoration of cleft palate, inasmuch as they have become classic, we
shall simply indicate the results which he obtained in those cases where
the cleft embraced both hard and soft structures — the only class of cases
occupying our attention at present.
Of the 51 cases of complete cleft operated on by M. Roux, four under-
went the operation a second time, and only one out of these four was
cured by the second operation. He pbtained occlusion of the cleft in
rather more than half of the cases operated on, that is, in 26 of his patients.
Our skilful surgeon had just reason to be satisfied with such a result,
from the fact, that the interval separating the two portions of the velum
pendulum palati is generally much greater, than in those cases where the
cleft affects only the latter organ. In fact, M. Roux, in most of his cases
practised the separation of the soft from the hard palate.
In terminating his work, M. Roux makes the following remarks : — " In
this class of cases we must not understand by success or favourable result
the simple union of the two portions of the velum pendulum palati. After
having obtained this result, which is ever incomplete, certain phenomena
resulting from the simple efforts of nature are soon to be observed. There
should be a spontaneous diminution of the distance between the two
portions of the bony palate, after which, should there still exist an opening
forming a communication between the mouth and nasal cavities, surgery
may again be called on to interfere, but by other than the former means ;
1 )i.imi' 1 on I I
« l may either attempt the definiti lusion of the -till exi^tir
h\ means oi palatoplasty or ire may limply maintain U oloeed bj
u obturator."
g that M. Eton length obliged to call in the ai
prothesis; but what services did these mechanical apparatus render to
patients? He is complete!} silent upon this matter, although ha moat
have had many opportunities of rerifying the results oi their employment.
Lot oi leave for the present this point of the question, in order to
opy ourselves exclusively with the 2o individuals to whom operative
surgery was of no utility, those whom both surgeon ami Burgery abandoned
to their sad fate. We .-hall mention the servioes which profhe tble
to render them, ami, alter having wrilied their reality, we -hall he allov
to establish a comparison between the resources, -" widely differing,
these separate portions of restorative surgery.
M. Uoux is the last surgeon who could plead ignorance, as to the
remarkable progress then realized by prothesis in the treatment of con-
genital cleft of the velum pendulum palati. In 1815, M. Stearns, an
American surgeon, exhibited to him and to his colleagues at the Academy
of Medicine, the serviees which a well conceived and adapted apparatus
was capable of rendering to individuals affected with this vice of
conformation.
The history of this surgeon is full of interest. Born with cleft palate,
ami arrived at the age of choosing his profession without having received
any efficient aid from the numerous practitioners of his country, M. Stearns,
fixed upon the study of medicine. With the old proverb, ";Aide-toi, le
ciel t'aidera," before him, he hoped by his own efforts to arrive with more
certainty at a means of remedying his infirmity.
The physiological study of the vocal apparatus soon instructed him as
to the role of the velum pendulum palati in the act of phonation, and M.
Stearns, being gifted with great mechanical aptitude, was not slow in
laying his hand upon the substance which was to permit him to realize
his desire. Some attempts had already been made with this end in view.
Nasmyth, dentist to her Majesty Queen Victoria, had constructed an
obturator, the posterior portion of which was composed of gold plates,
imbricated one upon another like the scales of a fish. This disposition
gave mobility to his apparatus, but its weight wras too great to allow of
its being easily raised by the column of air as it escaped from the glottis
in the act of phonation. M. Stearns had the happy idea to substitute
gutta percha for the metal, and, by an ingenious combination of plates of
this substance, he succeeded in constructing a light apparatus, which
answered very well its destined purpose.
Unfortunately caoutchouc, in the natural state, does not possess suffi-
cient resistance to the action of the agents, more or less destructive, of the
buccal cavity — viz., animal heat, acid secretions, and alimentary deposits.
affecting the Hard and Soft Palab 4!)5
M. Steams was consequently obliged to renew frequently bii artificial
palate; nevertheless, the greater difficulty was overcome, and tin- mo-
ohanical combination already arrived at, and it was not long before a
valuable discovery came in to crown the effort! of our confrert, by enabling
him to bestow upon his artificial apparatus the wanting qualities. The
vulcanization of caoutchouc allows it to remain in the mouth Pot months
without alteration, and, at the same time, in do way interferes with its
flexibility <>r lightness.
If the apparatus realized by M. Stearns was not appreciated by M.
Ronx, its importance did not escape the sagacity of Vidal dc (
inasmuch as we read in the edition of his work upon External Pathology
and Operative Surgery, which followed the presentation of M. Stearns at
the Academy : — " When the instrument is adapted, M. Stearns speaks
absolutely as if the structures of his palate were in a state of perfect
integrity, but upon its removal his voice assumes all the characters special
to persons labouring under cleft palate, and his language becomes unin-
telligible." He further adds : — " If this instrument can be fixed so that
there shall be no danger of the patient's swallowing it — if its attachment
to the teeth does not loosen them — if, in reality, its presence in the buccal
cavity be not irksome, and if its influence upon the voice and pronoun-
ciation be such as the experiment made upon himself, by this American
surgeon, seems to prove, we might, I believe, dispense with perhaps the
greater portion of the organic reparations at present practised upon the
palate."
On his quitting this country, M. Stearns failed to leave with us here in
France a model of his apparatus ; consequently, the instruction that he
came over to afford us as to his new application of prothesis was lost, and
his discovery wrould still have been buried in the archives of science had
it not been for a distinguished dentist whom we possess. M. Preterre,
upon settling amongst us, undertook to demonstrate all the reality of
buccal restorations by prothesis. His success has earned for him the
friendly esteem of our most eminent surgeons. In fact, M. Preterre came
forward with a generosity doing him infinite credit, in order to furnish us
publicly, upon our hospital patients, the proofs of what this branch of art
is capable ; and there is at present scarcely an hospital surgeon who has
not in his wards an example of the value of prothesis in buccal restorations.
Here it is a superior maxilla, removed in totality — there an inferior
maxilla, the anterior portion of which has been resected ; elsewhere a
cleft palate, now affecting the velum pendulum palati ; now the bony
palate ; and now all the structures indiscriminately, which we find
restored by the ingenious application of prothesis.
I have also taken advantage of the zeal of Monsieur Preterre in the
present instance. Having encountered an old patient of M. Roux, upon
whom he had performed, unsuccessfully, the operation of staphyloraphy,
[«* ■ IM-Pl h> tunu-h a* with the p,
! "1"1"- »■> "' *• improTemmiti ul.i.l, the model* ere,
- Nm bad under,,,,,, „ bJ, luUK,,. Tl„. lo„„u„
„""n' * «?P««W fc Co^wmW -'/,/,, „//;,,„,!/ M/l HatdandScfl
*-&****» of A, Lip at the ag, of | , ,„,,, ^
S^orapA, „ fl, ^ ,;|- nirtf-AppUeation, of Obturator! with J,
Lemaitre, mplop, :, i j .,„-, ,„■ ...^ born wilh „ |K.m.e affectin„ ^ ,eft
aided theupper li,,. The labial We to .ccompwued >y . teg, deft
;■' ""' to** ad wft paute. Hi, infirmity hindered him from t*L the
breast, and it was -me time ere a suitable meant of feeding him could
be found. Am ordmaiy tobacco-pipe was first employed ; the bowl bein-
filled w„ , milk the thumb was placed upon it, and the stem laid upon the
base ot the tongue, when, by alternately lifting and replacing the thumb,
Fife'- 1.
one was able to control its exit. At a later period a small bottle was
employed in the following manner :-It was filled with milk, and a morsel
o sponge the s.ze of the little finger, and about two inches in length, was
attached by means of a piece of linen to its orifice. With the aid of this
affi r/i/i,/ the Html and Soft. I'dlates. 41)7
surkiiiLT bottle Lemaitre was reared, i > u t oof without difficulty, and con-
sequently bis mother eagerly accepted the operation immediately nponits
being proposed. The restoration of the bare-Up was attempted with full
success al the age of sis weeks; but, the Burgeon not having incised snffi-
eiently the left nostril, Lemaitre was left with th;it ride of his nose much
flattened, as may be observed by die wood cut A, left nostril, which
has remained flattened, owing t<> tlie insufficient division of the npper
portion of the nasal Ussiwe. In the anterior portion of the palatine fissure
the vomer, B, is observed fixed tothelefl maxilla. The distance separating
the two portions of the velum pendulum palati is much greater than usual,
Owing to the unsuccessful attempt of M. Roux at staphyloraphy. At the
back of the mouth we may perceive a kind of muscular layer, C, projecting
forwards, especially during the act of deglutition. It then seems as if the
posterior pharyngeal wall (under the influence of the contraction of the
pharyngo-staphylinus, or middle portion of the palato-pharyngeus) is
projected forward as if to close the existing cleft.
Inhabiting the country, and occupied with field work, he felt less the
inconveniences of his infirmity than he would have done had he dwelt in
a city, and been engaged in an occupation requiring more frequent inter-
course with his fellow- workmen. But still this man, who is very intelligent,
acutely remarks, that the country people being less intellectual than
townsfolk, he frequently had much difficulty in making himself under-
stood by the former ; and, on this account, he decided upon taking a
situation of shop-boy at Havre ; and it was in this place that M. Isidore
Geoff roy Saint Hilaire, in the year 1847, proposed to bring him to Paris,
in order that he might be operated on by one of our skilful surgeons. The
mockeries of which he was from time to time the object, and especially
the desire to be able to speak as distinctly as the rest of us, induced him
eagerly to accept the friendly offer of the illustrious naturalist.
Lemaitre, on his arrival in Paris, was immediately confided to the care
of M. Roux, and placed by him in his ward of St. Marthe, at the Hotel
Dieu (No. 7). After the usual preparatory treatment, M. Roux performed
the operation of staphyloraphy. Three sutures were applied, and the union
was so rapidly accomplished that, at the expiration of 48 hours, M. Roux
thought himself warranted in removing the sutures. That he was too
hasty was proved a few hours later by the re-separation of the flaps, thus
reproducing the fissure, and leaving the infirmity greater than before.
Immediately after the removal of the sutures a glass of wine was given
to the patient, and Lemaitre, who up to this time had been perfectly free
from fever, now began to suffer from quick pulse and other signs of an
alteration of his health. Under these circumstances what influence must
we attach to the moral effect of the disappointment in seeing all his hope3
destroyed ?
The fact is that, under the influence of these exciting causes, an erysipelas
VOL. XXXIII., NO. G6, N. S. Q
Di ! ration of Congenital 1
of the scalp manifested itself upon the fourth da) following the operation,
and became bo inf ite an incision behind the right i
This attack of erysipelas was the principal cause of his not ondergoin
second operation. Immediately upon his recovery he quited the Hotel
Dion.
Lemaitre, ashamed of returning t<» 1 Ia\ re -till Buffering from his infirmity,
and haying relations in Paris, preferred staying here, and it wbb not L
ere he found employment. A few months since, coming by accident
across this man, it occurred to me to make use of him in judging the value
of prothesis in cases of cleft palate affecting simultaneously the hard and
soft structures, and I conducted him to M. Preterre. The wood-cut Fig. 1,
indicates the extent of the lesion left for this dental surgeon to repair.
On the 1st of November, 180" 1, M. Preterre adapted the first model, a
copy of which we adjoin : —
Fig. 2.
Plaster Cast of the superior Maxilla of our Patient, and Model of the
Obturator destined to close the enormous Fissure.
The plaster cast indicates the irregularity in the position of the teeth,
affecting the Hard <m<l Soft Palates. 4 *♦'.»
the incisors and canines bearing especial evidence of the congenita] Lesion.
Tin- fissure is Long, Large, :m<l gaping, commencing ;it the onion of the
anterior third with the posterior two-thirds of the bony palate, and then
dividing the velum pendulum palati, so aa to suppress the uvula, and Leave
intact only the anterior pillars. Its limits are denoted in the plate above
by tin' dotted lines.
The obturator is summarily composed as follows: — A metallic plate (3)
is exactly moulded to all the inequalities of the remaining palate, and
nicely adapted to the teeth, sending out prolongations in the dental
interstices, in order to give fixity to the apparatus* Allow us here to
mention, as a peculiarity, that in this case the plate of gold is cut out in
such a manner (5) as to leave uncovered the gustatory papilla?, situated
behind the incisors. But this disposition is not always, or even often,
practicable, owing to its interference with the solidity and adherence of
the apparatus. To the posterior border of the plate (3) is fixed another
metallic rim (4), by means of three tenons turning on their axis, fixed
upon the plate (3), and fitting into mortices of the plate (4). These tenons
and mortices are indicated by the letter (E). It is between the plates (3)
and (4) that the flexible velum of caoutchouc (1 and 2) is fixed. But the
plate (4) serves another end besides the fixation of the artificial velum —
it affords support to a whole system of springs, maintained in place by six
screws, three on each side.
The caoutchouc, being moulded upon the soft parts, and to the edge of
the fissure, presents different degrees of thickness, necessitating the em-
ployment of springs, differing in their force according as the caoutchouc
differs in thickness. These springs may be enumerated as follows : — In
the median line is observed a pendulum or needle-spring (C C), the lentil
or weight of which may be made to approach or recede from the centre
of oscillation by means of the screws (D D). The force of this spring is
considerable — it is due to the action of a tempered gold wire, arranged in
the form of a spiral (A A), and fixed to the upper surface of the plate (3).
The energy of this spring may be further modified, either by loosening the
spiral or by changing the position of the nut working upon the screw
(B B) ; the mobility of this nut is itself regulated by a flat spring, twice
turned upon its horizontal axis. Further outwards, on either side of the
spring (C), we have a flat spring of tempered gold wire. These springs,
attached to the plate (4) at the junction of the external with the middle
third, are carried outwards and far backwards, to be fixed to the thinner
portion of the caoutchouc ; and, lastly, we have at each outer edge a spring
of the same nature, but much shorter, and corresponding to the thicker
portion of the caoutchouc.
This model had perfectly succeeded in a case of M. le docteur Cornag, of
Neufchatel; and in the month which has now elapsed since this apparatus
has been worn by Lemaitre, with the assistance of an hour's daily exercise,
Q2
500 Dl BOl i on Rs$toration of Congenital /■<
Mperiateaded by M. P tki with rarpruiBg eaee. This
rapidity of result ienot usual, ami depends apoo the great intelligent* and
U'lutciiv of the patient,
[nasmnch ai M. Prftterre shortly intends to read before the Academy of
lieine a paper upon the apparatus destined to remedy congenital deft
palate, and on the special education necessary, as part of the treatment in
such oases, 1 ihall not enter upon tliis subject, but content myself with
the mere mention of the good results 1 have vritnessecL
There is, however, an error which I should wish to point out — an error
under which the greater number of medical men still labour — and that is
that so soon as the artificial palate shall be adapted, the subjects of con-
genital cleft palate should be able to speak immediately, and correctly.
By promising such a result to their patients, they lead them into eerious
error, and cause much bitter mortification to the artists undertaking the
prothesis of this deformity.
In order to understand this fact, we have merely to call to mind the
altered conformation of the different parts of the vocal apparatus, and the
role which they are suddenly called upon to perforin.
The upper lip has, in point of fact, been restored — that is, the fissure
which it presented no longer exists, but the labial tissues are far from
being normally organised. The muscular tissues have suffered in their
development ; it is less abundant at the point of reunion : and this portion
of the lip consequently possesses less mobility ; moreover, there exists
almost invariably at the inferior extremity of the cicatrix a notch more
or less evident. From these modifications it happens that, whenever
individuals who have been operated upon for hare-lip pronounce labial
sounds — as eu, ou, &c, the under lip takes more than its share in the
movement ; and, besides, there is an effort to close the notch or slight
remnant of the ancient fissure.
The conformation of the palate is not less vicious ; the separation of the
bony halves of this arch enlarges the buccal cavity, and diminishes, in a
relative degree, the nasal fossae ; and it is evident that the application of
an obturator can only close the communication between these cavities, and
in no way remedy the modifications depending upon the change in their
relative capacity ; and it is this alteration which especially influences the
tone of voice, which most frequently is, in these cases, snuffling, especially
when the nostril remains flattened.
Lastly, Ave arrive at the role required of the artificial velum pendulum
palati. The mechanical problem was difficult to resolve ; for, although
the plate of caoutchouc is as soft and flexible as the natural soft palate, it
is unprovided with muscular action. Here it was that the artist had to
call to his aid all his ingenuity : he had here to create a factitious force,
which could raise the velum to the height necessary for the act of
phonation. M. Preterre, in the apparatus designed in the present paper,
affecting tJic Hard and Soft I'alates. 501
bftl attained this object by, in the lirsl |>l:ir<\ giving the plate of eauutehouc
a greater thickneea at ill bate ; and, secondly, by the application of a serial
of gold springs, which he lias succeeded in rendering as flexible a- steel.
When one reflects upon these, modification*, as well organic at prothetie,
and the inllnence they necessarily exert upon tlie phonic apparatus, one
easily understands that the individuals suffering I rom this infirmity,
although pOSSeesing the mOSl Complete apparatus, must still devote them-
selves to an especial study, and that the time necessary should be not less
than from three to six months; the result is the more complete, as the
lesion is less profound, and the Individual possessed of greater perseverance.
Now that we have established by facts the reality of the resources of
prothesis in the treatment of congenital cleft palate, it may seem that we
have now only to trace the comparison between the advantages offered, on
the one hand, by the new apparatus, and, on the other, by operative
surgery.
But, previously, we must mention the distress occasioned by this vice of
conformation, in order that it may be placed in the balance against the
inconvenience of obturators, and the dangers of autoplasty. This view of
the question is completely neglected in the classical works on the subject,
notwithstanding the influence which this point ought to have in determining
the surgeon to interfere, and the weight it should exert in the choice of
means to be employed.
The distress occasioned by congenital cleft of the palate varies greatly
at different periods of life. At the age favourable to surgical interference,
the infirmity merely affects the organs of speech ; of whatever extent the
cleft may be, these individuals swallow with the same facility as if the
internal conformation of the mouth was normal. This is by no means the
case at birth.
Cleft palate, affecting all the structures, is one of the deformities most
directly compromising an infant's existence, by the obstacle it offers to
suckling a The silence maintained by authors on this subject, as well as
upon the artifices to be employed in these cases, induces us to reproduce
the first portion of a very interesting paper addressed by Eustache (de
Beziers), in 1778, to the ancient Academy of Surgery. This paper would
have remained unknown had not one of our most distinguished rising
surgeons, M. Verneuil, undertaken to scrutinize the archives of this
celebrated association, and to publish such fragments as might be useful
to science. Although his publication was arranged with an especial view
to the history of Staphyloraphy, our sagacious confrere has taken care to
* In the 15th number of the Compendium de Chirurgie, which has appeared since the
termination of this article, we find the following assertions : — "Congenital division of
the velum pendulum palati does not compromise existence."
" One ought not, in these cases, to reckon upon the applications of prothesis."— (Page
754). These lines furnish us with further proof of the importance of our study.
De bout on j
point <>ut the value of thif communication regarding our pi
S i, here, tin- entire document. We must at present notice that Eustache
employs an improper expression in speaking of the ri (nation
rice of the velum pendulum palati. Thifl error, bj indicated by If.
\ rneuO) depends upon the smallness of this organ at birth, rendering the
• portions but slightly visible. Having mentioned this error, vre return
to our citation.
Observations on Several Cases of Children Burn, with the Vdum Pendulum
Palati Absent : followed by an Essay upon a Means of Reuniting AV
Divisions of thai Organ, 1>> El ma. be ds Beziebs.
"... Every one is aware that the soft palate i- especially destined
to moderate and direct the descent of food and drink, and to hinder then
from ascending into the nasal cavities; that it further serves to direct the
air expired ; that the act of swallowing depends on it, as well as the charm
of the voice and the sonorous articulation of words. But if this lleshy
partition is so essential to the adult, it is not less so to the new-born
infant, to enable it to suck from its mother's breast the vital juice so
admirably elaborated in its veins by Nature. The case of one of my own
children, observed with all the exactitude that paternal tenderness could
inspire, will furnish evident proof : —
" Obs. I. — First Observation made upon one of my Children, Born with
complete Absence oftheVelum Pendulum Palati. — In 1778 my wife was safely
Confined with a male child, which appeared, at first Bight, well developed.
Some little time after birth a little syrup was given him ; this he had
scarcely tasted when he was suddenly seized with a convulsion, almost
general. I attributed this accident to the entrance of a few drops of the
liquid into the larynx. Recovered from this disastrous accident, he WSJ
put to the breast : he seized the nipple with avidity, quitted it, reseized
it with uneasiness. Others were presented to him, which he seized, but
always with the same agitation, and without success. I was too deeply
interested in the conservation of this tender being not to occupy myself
seriously with the discovery of the cause of such an effect. I examined
the mouth, and at first sight discovered no anormality in its structure ;
but as the accidents still persisted, I examined the buccal cavity a second
time, and at length perceived at the entrance of the throat an extraordinary
opening, which led me to the conclusion that my son was born without the
velum pendulum palati.
" However, two days had already elapsed, and, erat periculum in mora, I
therefore decided to administer a small spoonful of goat's milk : of this he
swallowed some few drops, but the greater portion returned by the nostrils.
I repeated this method, but with little success. On the fourth day of all
these perplexities I imagined the use of a long and thick brush, which I
made of linen. This I soaked in milk, and presented to him ; he seized
effecting tin' /lord and Soft Palates. 503
it, and was able to suck it. This little artifice having always succeeded
it W«« employed for seven consecutive days. Kmholdcncd by this success,
I made a second brush, 1 his time in the form of the nipple, and this artificial
nipple enabled him to become accustomed by degrees U) the natural one;
and ten days afterwards he began tO take the breast, hut always with
much difficulty and extreme slowness, and this caused him to waste away
most pitifully.
u Within the space of five months he had ten wet nurses, and all avowed
to me that this unfortunate infant, although applied to the breast for hours
together, did not succeed in extracting half an ounce of milk in the whole
day. Hence the almost total suppression of the urine and other excretions.
Another nurse now presented herself, and animated by interest — that great
and powerful motive — she engaged to take charge of this infant, in spite
of the worry and embarrassments attending him. She had him under her
charge during fourteen months ; but, as she has since admitted, becoming
wearied, and observing the daily wasting of this poor infant, she contrived
in order to shorten her labour, without losing her salary, to feed him with
a pap composed of equal parts of milk and water sweetened ; and this
method was secretly followed during thirteen of the fourteen months of
her nursing. But this did not prevent her from applying him to the
breast, in order to screen her conduct ; but this application was always
followed by convulsions and violent fits of coughing.
" However, he lived, and was weaned at the nineteenth month, when, to
our great consolation, our infant got gradually stouter, his flesh became
firmer, and his eyes expressed more animation, fluids were more rarely
returned by the nose, and in the space of three weeks there was such a
change in his health as I had not dared to expect.
" You easily understand my anxiety to discover the cause of such a happy
change. I found it in the commencing development of the soft palate.
This development daily increasing, things took their natural course, and
my son was in a great measure delivered from the fiercest accidents which
had so much alarmed me. From this epoch the deglutition of solids has
always been accomplished with facility ; but this has not been the case
with fluids, especially in the case of water, the swallowing of which has
always been laborious. The only liquids passing with less difficulty were
red wine and muscat, their spirituous quality putting, without doubt, the
organs of deglutition in action. We must further remark that the simple
fact of inattention on the part of my son, either in eating or drinking, or
the fact of the slightest obstacle touching the laryngeal orifice, produced,
on the instant, a violent fit of coughing, which shook the whole of his
muscular system. Lastly, we must mention that this tender infant, having
without doubt learned the injurious results of the rapid descent of liquids,
retained them in his mouth in order to swallow them insensibly, drop
by drop, as it were, and this by a natural instinct more sure than the most
1 )i BOl i on ( ition of ( 'ongt
ivh l allowing be bad also the precaution oi in
rwards, as in th<* case <>f ih*- Portuguese girl, related by II. do
Jussieu.*
•• Prom all of tl. its, scrupulouslj observed, Li leemi evident that the
velnm pendulum palati bi absolutely necessary ially to new-born
infants, and thai ii serves, al all ages, principally in the deglutition oi
liquids; and, secondly, that it is further of marvellous use in sonoi
articulation, and in giving to the voice its agreeable qualities, as 1 have
previously observed, and as the following fact will demonstrate : —
• ly son, whose sad situation 1 have just described, remained at if
dumb until the age of four jean, or it' he spoke, it was, in I manner, un-
intelligible. At this period he began to pronounce more distinctly, but
his voice was always embarrassed, ami wanting in flexibility. In order
to overcome this inflexibility, I thought of causing him to tattle unceasingly,
in order that the frequent vibration of the fibres of the glottis might render
them supple and nimble, and thus remove the Stiffness and harshness so
painful to me in the voice of my son. This expedient perfectly succeeded :
by means of this continual babbling, which I took care to animate, his
organ became supple and pliable to the most varied inflexions : the air,
which, by the constant movements of inspiration and expiration, quits the
Inngfl or enters them by the opening of the glottis, caused an insensible
vibration in the nasal fibres by the accelerated movement of an uninterrupted
tattle."
Eustache continues : —
•• A modern philosopher considers the organ of voice as a Stringed in-
strument. The air escaping from the lungs is driven against the tendinous
fibres of the glottis, causing them to give out sounds, the result of their
vibration. Upon the flexibility of these fibres or vocal cords, upon their
agility, and upon the precision of their vibrations, the voice depends for
all its agreeable qualities — as the clearness of sound under ordinary
circumstances, the softness of warbling in song, the delicacy of a modu-
lation, and the brilliancy of a pearled cadence. But, in order to produce
all these agreeable effects, there must be no deformity of the buccal cavity.
You are aware, gentlemen, that such as are deprived of the soft palate,
well as those in whom this membranous partition is divided, have a
disagreeable nasal tone of voice. This was the case with my son ; for,
although by the means employed as above described, he succeeded in pro-
nouncing very distinctly, his voice was far from agreeable — he spoke
through the nose, from the fact ^t the air, upon its escape from the
glottis, not being directed by this partition into the posterior nares ; on the
contrary, the greater portion passes by the mouth, and the sounds formed
not being reflected into the nasal cavities, the voice has no agreeable
qualities.
* Memoires de l'Acad^mie des Sciences, 1718.
affecting the Hard and Soft Palatet. ;">(>.">
UI pass over in silence in; my other phenomena obser\ed upon my infant.
M. Dodart, who has written ah admirable paper upon the mechanism of
the voice,'1 treatfl thlfl matter in a manner whieh embellishes and fortifies
my observations ; bat, inasmuch ai the \ ain display of Learning would add
nothing to tin* rarity of the tacts I have just exposed, I shall content
myself with referring my readers t<> bis paper.
" I have frequently presented my son t<> many members of the Academy
of Science and Belles-lettres of this city, and the different experiment!
above related were performed in their presence. It is now about three
months since this dear child died from an attack of small pox. He would
at present have attained his fifth year.''
Subsequent Observations in support of the above.
" Obs. II. — M. Rey, Avocat au Parlement, called me in on the 12th of
October, 1779, to see his daughter, aged twelve days. M. Foulquier, the
surgeon generally attending the family, informed me that it had been
impossible to suckle this child, and that its only nourishment had been
goat's milk, administered in small spoonfuls. On examining the buccal
cavity, we found that this child was deprived of the velum palati almost
in the same manner as my son, but with this difference — that in the place
of the pillars there was on each side a caruncula the size of a pea, and at
the point corresponding to the articulation of the cuneiform apophysis of
the occipital with the body of the sphenoid, there existed a fleshy excres-
ence the size of a bean. I determined upon following the same course as
in the case of my infant. This little one commenced to suck from the
breast on the sixth day, but with great difficulty ; the greater portion of
the milk returned by the nose. She was sent out to a wet nurse in the
country, but afterwards brought back to town by my advice, but all in
vain. The same vice continuing to exist, the difficulty of suckling
remained the same, the convulsions redoubled, extreme wasting resulted,
and the little patient fell into a low fever. The impoverished state of the
blood occasioned, in different parts of the body, tumours which suppurated,
death at length closing the scene after five months of suffering.
"Obs. III. — On the 6th of June, 1781, Dr. Rouillet begged me to see
the child of a M. Fabregues. The child was twenty days old, and all
attempts to suckle it had been fruitless. On first sight it was perceived
that the infant was the subject of hare-lip. The slightest drop of fluid —
all of which, besides, returned in a great measure by the nose — excited
violent convulsions. I attentively examined the interior of the mouth,
and clearly perceived that the soft palate was wanting. The rest being
perfect, I ordered the administration of pap, which was easily swallowed,
but his stomach not being able to support this kind of food, he perished
on the twenty-fifth day after birth.
a Acaddmie des Sciences, Annee 1700.
1 )i ibOI i on R l -uuU Fissure
i\ Mi -.in, merchant, I P - > ias,c i isnltedmeon tin- l ith
of Jim about his daughter, n ho, fifteen daj - old, bad not been able
to take the breast op to that time, the Least liquid causing suffocation.
The earns means employed in my son's i n resorted to — she
deprived in the same manner of the velum pendulum palati — hut all in
i. When applied to the breast the accidents were renewed, tin; liquids
did not pass : she fell into the last degree of marasmus, and expired th.
months after birth.
" Ons. V. — On the 12th of September, 1781, I was called to an infant
of Jacques Visset, blacksmith, at Sauvain, a village a league distant from
Beziers. M. Yalouzieiv, master of surgery, met me there. This child,
only eight days old, had not been able to take the breast, ami had suffered
similar accidents to those related in the preceding cases. On examining
the mouth, we became convinced of the absence of the soft palate. I
ad\ ised the child to be fed with pap, which was easily swallowed ; suckling
9 from time to time attempted, but without success, every attempt
renewing the anxiety and distress. She died on the fortieth day after
birth, wasted and extenuated.
" Obs. VI. — The following case was communicated to me by M. Cabanon,
matt re en chimryie & Capestan, three leagues from Beziers. He was called,
during the month of September, 1782, by Andre* Esperon, to see a child
four days old, whom they had been unable to suckle, and to whom it had
not been possible to administer liquid of any kind.
"It resulted, from the examination, that this little patient had no soft
palate. So long as she lived she was fed with pap ; without being very
stout, she seemed in tolerable health. Almost the entire village were
witness of the fact that, whenever it was attempted to administer any
liquid, the child was in danger of Buffocation, and that the fluid was
almost entirely ejected by the nostrils. She died suddenly at about the
age of nine months, without its being possible to determine the cause of
death.
"From all these observations I conclude that, whenever an unfortunate
infant is born without the velum pendulum palati, that it is essentially
necessary to feed it from the lirst with pap ; but, especially, we must
abstain from applying it to the breast. The difficulty experienced in the
act of suction, the accidents which result, the convulsions which follow,
with the anxiety tormenting him, are so many causes of irritation, pro-
ducing marasmus, &c, and conducting at length to the tomb. If I had
in every case followed this method, perhaps not one of these tender victims
whose cases I have related above would have perished. I leave this
reflection to your judgment."
The following remarks are those which M. Verneuil appended to the
observations of Eustache : —
affecting thv I I<w<l <ui<l Soft Palates. .r)07
"Before producing the second part of this paper, where we Bhall find
the operation of Btaphyloraphy indicated, and described in so remarkable
■ manner, I desire to dwell a short time upon the preceding facts, in order
to show all their importance — abstraction being made <»t the question of
operative surgery.
" The primitive malformation now occupying our attention was already
known ere the end of last century, were it only l>y thon- surgeons who had
observed complicated hare-lip. But we believe that, previous to Eustache,
none had studied the simple lesion, as confined to the soft palate: it is
certain that no one had, previous to this, so exactly described t lie conse-
quences and prognostics. Our author, on the contrary, after having
described and insisted upon the essential uses of the velum pendulum
palati, enumerates very faithfully the accidents resulting from its vicious
conformation, viz. : — the impossibility, and even dangers, of suckling ; the
imperfection of language from default in the pronunciation, &c. After
which he indicates the proper means of preserving the precarious existence
of the unhappy beings thus affected ; and he demonstrates the efficacy
of his councils by the example of his own son, who survived the first year
of existence, only perhaps on account of the minute care taken to insure
his alimentation.
" The series of facts produced by Eustache demonstrate the extreme
gravity of congenital fissure of the soft palate — gravity partaken by this
deformity with congenital fissure of all the structures, lip, hard and soft
palate, and upon which modern authors themselves do not, perhaps,
sufficiently insist. Upon a given number of infants born with an
extensive fissure of the palatine arch, how many survive and how many
succumb ? This, exact statistical documents do not permit us to decide ;
but it is certain that a very large number perish at an early period.
This is a fact pointed out by Dieffenbach and others, and which has
been, on many occasions, confirmed in the discussions of the Society de
Chirurgie. Further, it is evident that the prognostic, other things being
equal, is more serious in cases of fissure of the velum palati than in cases
of hare-lip, inasmuch as the latter may be remedied at a very early age,
while the operation of staphyloraphy is almost unanimously postponed to
the period of adolescence, and not without good reason.
" One will further remark in the case of the son of Eustache, the kind
of vocal gymnastic instituted with success by the father ; also, that
secondary increase of the velum palati, being a kind of natural autoplasty
by which the soft palate seemed, towards the twentieth month, to
become much more developed posteriorly."
In a nosographical point of view this first portion of the papers by
Eustache presents most incontestible interest ; it may also be consulted
with advantage by such surgeons as would write a useful paragraph on
DEBOUT OH J ' / ire
the precauh re the existence of infants affected with congenital
the velum pendulum paiati.
This hiatus, to which ML Verneui] m justly drawi attention, baa long
truck u>, for pre bave, ai the profession if aware, paid particular
attention to the therapeutique of primitive rices of conformation* In all
the obeervationi of individual! affected irith cleft palate which hi
fallen under our notice, \vc have carefully remarked the I attention!
employed during their lactation, and to which they were indebted fot
their existence.
These artifices vary according to the extent of the congenital injury.
When the solution of continuity affects merely the velum palaii, as in
the case of the son of Eustache, maternal suckling is still possible; but,
in order to its facility, the infant musf be applied to and retained at the
breast in the vertical position. It was in this way that M. Stephenson
(the American medical man upon whom M. Row performed his first
operation of staphyloraphy) was nursed. M. Roux took care to point
out this happy inspiration of the mother of M. Stephenson in his first
paper upon this subject, and he repeats that he has since had many
occasions to recommend the same precaution, and that he has seen it
succeed in every case where the injury was the same in extent. This
expedient is of more value than that of Eustache, inasmuch as many of
the infants which he caused to be fed with solid aliments succumbed.
seen by his observations. If his son survived, this result was owing to
his continued application to the breast, in spite of the administration of
pap, and especially to the incessant attentions with which he v
surrounded.
When the cleft velum is accompanied by hare-lip, single or double,
which is frequently the case, maternal suckling is no longer to be thought
of, the infant not being able to seize the nipple. In these cases, as in
that of Lemaitre, a sucking-bottle must be resorted to. The nipple of
this instrument must also be longer than under ordinary circumstances ;
and again, its orifice must be narrow in order to allow a feeble flow of
it- contents; the act of deglutition being very slowly accomplished, there
is thus no penetration of liquid into the air passages.
But, to return to our principal subject, which we may do without
quitting the interesting observations furnished by the Surgeon of Beziers.
It has been observed, that immediately on the child being weaned,
Eustache no longer speaks of the obstacles to the alimentation of his
infant resulting from the bilidity of his palate; the fact is, that the
education of the parts has been promptly accomplished. In spite of
their infirmity these little patients are not long before eating and drinking
with the same facility as healthy subjects of the same age. One sees
that upon the child being weaned, the arrest of development ceases to
compromise its existence.
effecting //"■ Hard and Soft Palat 509
At this period i aew series <>f trials trite — those relating to the phooie
apparatus, and these are of longer duration* Although the Or I cries ol
the infant may be unmodified by the cleft palate, thit it uo longer the
ease with articulate sounds, to toon at the epoch arrives when the child
begins to talk. The incomplete development <>i these parts renders
Speaking laborious, and infants affected with this \ ice of conformation must
needs be incited; if they are abandoned to themselves they remain mute,
or only utter sounds ill articulated. Without great patience and especial
attentions, similar to the example furnished US by Eustache, we cannot
arrive at the removal of this state of things, and the voice remains
offensive and disagreeable.
This imperfection of speech exercises a serious influence upon the
character of these infants, although they may make themselves understood
by their parents, it is no longer the case when they address themselves
to their little comrades, who refuse to allow them to join in their games.
Again, at a later period, when the moment of commencing their education
has arrived, the difficulty of making themselves understood disables them
from profiting from the advantages of public instruction. Deprived of
the stimulus of emulation and remaining at home, they study but little,
work badly, and become unceasingly discouraged, and rarely arrive at
the completion of their particular studies.
And still, by perseverance and a but slightly special study, commenced
at an early age, this vice in their pronunciation might be so far corrected
as to allow them to become acquainted with other than mere family life.
It is not necessary that the amendment should be so very considerable,
in order to suggest to them the idea of entering into society, it suffices
that their conversation becomes comprehensible. Accustomed from their
infancy to their mode of speech, they are only imperfectly conscious of
their defective language, and so soon as their hearers manifest no difficulty
or fatigue in conversing with them, they forget whatever there may be
unusual in their manner of speech.
Reading aloud, declamation, and even singing, are the exercises most
adapted to improve their pronunciation. Under the influence of this
gymnastic, the voice attains a greater extent, becomes less veiled, less
nasal, and articulation of sounds less defective. Here we observe
something analagous to what has already taken place with regard to the
deglutition of liquids. When one observes these extensive clefts of the
palate, one is astonished to see the subjects of them drink as naturally
and promptly as if the palate were in a state of perfect integrity.
Nature possesses an infinity of resources. Should the integrity of an
organic apparatus become compromised, its functions are not, as a conse-
quence, destroyed. At first, their exercise is more or less interfered
wdth ; but if, by a forced and constant gymnastic, the remaining parts
are brought into action, we gradually see the inconveniencies which had
l)i it* » i i on Restoration
arisen disappear, and the apparatus, however incomplete it maj I
ire, its functions. "Lafonction fait l'oi
If, J, Guerin; \w hart ■ new proof of this dogma. Deglutition
an acl of organic life, incessantly reproducing itself, the education "i the
remains of the palate, is quickly accomplished, and even liquids are, in ;i
short time, ingested without accident. It is different with regard to the
concurrence of these part- in the act of phonation. This function
under the control of animal Life, and exacts the concourse of the will,
and of a will the more energetic according as the alteration in structure
renders its accomplishment more laborious. However, it is but a difficulty
which may be overcome by the prolonged and oft-repeated exercise of
the injured organs.
Should the results leave us still something to desire, especially concerning
the nasal tone of voice, we have the resources of prothetic apparatus.
In the example we have given of the excellent results of the employment
of an obturator with artificial velum, the patient was fifty-four years of
age, and still his education, as we have remarked, was more rapid than
that of individuals much younger. The desire of succeeding, comes in aid
of the injured organs. But this is not the only example which we have at
present before us : M. Preterre has shown us many cases of young people
now under his treatment. We intend to publish, at a future period, the
complete notes of these cases.
It is especially the young who will reap the greatest benefits from pro-
thesis, and more peculiarly those already enjoying a large share of physical
qualities. Nothing spoils so much the charm of beauty, or tarnishes its
brilliancy, as the imperfection of language such as results from cleft
palate.
The greatest obstacle to the common use of the obturator, with
movable velum, is the cost. Allow us to remark that the price of such an
apparatus is not at all exorbitant; and, further, that these prothetic aids
are indispensable only to the easy classes of society. M. Roux will again
furnish us with proof : — " One conceives that, to a man destined to manual
labour, necessitating but slight intellectual intercourse with his fellow-men,
such and such a tone of voice is of little importance, and that even the
most defective manner of speaking rigorously suffices him. Of what use
would a more perfect language be to him ? Consequently, a man in this
condition rarely makes any great effort to alleviate the results of this
deformity ; and it is even difficult to instil into him a desire to be delivered
of his infirmity. I can easily count, so few is their number, the peasants
and individuals belonging to the lowest classes of our city populations
upon whom I have practised staphyloraphy ; and, again, the greater
number submitted to the operation rather from the persuasion which
chance threw it in my power to exert on them, than from any prospect of
great change in their manner of speaking. I have seen patients refuse,
affecting the Hard and Soft Palatee. 511
at the last moment, tO BUbmit to the Operation to which they had previously
consented."
We have sufficiently enlarged upon the resources offered by prothesis.
Let us now say a few words as to the succour held out by operative
surgery. When tin- fissure affects simply the velum pendulum palati, the
results of antoplasty are complete, and, in this case, superior to those of
mechanical prothesis; but when the fissure extends to the hard palate —
and it is these eases we have especially in view — it is no longer the same,
The sum-eon can only unite the two portions of the velum pendulum palati,
so that there is still left the breach of the hard palatc.a At the age when
staphyloraphy may be attempted with success, there is no longer any hope
of seeing the bony portions of the palate unite by a natural approximation ;
the patients will, in spite of the success of the autoplastic operation, be
obliged to resort to some artificial means of closing the remaining
aperture.5
Previous to the epoch when the artists devoting themselves to buccal
restorations had succeeded in constructing an obturator with an artificial
velum capable of supplying the place of the normal soft palate, operative
surgery was in the right whilst seeking to establish the continuity of this
membrane, inasmuch as the parts were thus placed in such a condition
that prothesis could complete the work of restoration by the simple
adaptation of a metallic plate. But, is it now the same ? Evidently not.
Since the individuals affected with complete cleft of the palate are com-
pelled to wear an instrument, that this apparatus should be more or less
complicated is a question of slight import. The palatine plate is the most
embarrassing portion of the piece, from the many points of support which
a Since our principal object is to demonstrate the resources offered by mechanical
apparatus, we must recall to mind an article which we published long since, "On the
Employment of Maxillary Compressors in Cases of Hare-lip, complicated by congenital
fissure of the palatine arch, and of the projection of median tubercule. — (Bulletin de
TheVapeutique, t. xliv., p. 254 et 447.) — To the facts which we produce in support of the
good effects of these apparatus, we must add the following, which was borrowed by M.
Roux from the practice of Montain (de Lyon). We quote the words of M. Roux : —
"This operation (the staphyloraphy) was scarcely created, and the first results I had
obtained by it scarcely known, when M. Montain and myself had simultaneously the
same idea — that of provoking in very young subjects the approximation of the two
portions of the palatine arch in cases where the cleft affects this as well as the soft
palate. Each conceived the idea of a double compression, applied on each side to the
superior maxillse. In one case he treated, and obtained this approximation of the two
separate portions of the palate, the patient was but a few days old. He afterwards
obtained complete adhesion, but without employing either scalpel or suture : he con-
tented himself with cauterizing, at intervals, the edges of the remaining fissure, and
thus obtained occlusion."
b It will be seen by reference to the able paper of Mr. M. H. Collis, in our 21st Vol.
that Dr. Debout quite under estimates the value of autoplastic operations. In the
Report on Surgery in our present number, p. 43C, some further suggestions on the
subject will be found. — [Ed.]
DEBOl i on I', notation of I nital I yc.
it has upon the tooth ; whereas the ph ol the tongue quicklj
>iiu' Accustomed to the contact oi the artificial velum; and, mi
the trial ol such as apparatm Lb inoffensive; and ai it may be applied at
■ tame oi life vrhen itaphyloraphj is still impossible, oothing hind
being tried. Should it be found fronting in efficiency, do time bat b
tost, and the patient can always claim the .succour of autoplaaty, and
will take bis determination with a knowledge of the cause. Should the
operation of staphyloraphj oof Buceeed, be oan again return to the use
of hie obturator with movable velum ; all that would be n is the
ilight enlargement of the plate of caoutchouc, the nssju • having been me
larger, and a ilight increa.se in the force of the ipring supporting this
plate, inasmuch as the muscular tissues pressing upon tn artificial velum
would have been weakened.
Besides, we can strengthen our opinion by that ol* an eminent -urgeon.
Since lu' has observed, as ourselves, the results furnished by the obturator
with movable \elum, M. Nclaton has completely renounced the practice
of staphyloraphy in cases of cleft affecting the hard and soft palate, even
in those oases where there exists no deformity of structure: as, for
example, in cases where it has been necessary to sacrifice the palate in
the extraction of a fibrous polypus from the nasal fos-a\
In the actual state of science we do not hesitate to declare that in c
of complete cleft palate — that is to say, in cases where the tissure affects
both bony and soft structures — the resources offered us by prothesis are greater
than those of operative surgery.
DEBOUT, D.M.S.,
Member of the Surgical Society, and President of the
Medical Society of Paris.
Bulletin General de Therapeutist.
/.'
513
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wiirde, der hohen philosophischen Faeul-
tat der llochshule zu Bern, uberreicht
von Rud. T. Siuimler, von Zurich. 1861.
pp. 69.
Progranim der Pernor Kantons-
■ohnle. 1861.
3'!. Veraeichniss der Vbrlesungen
welche an der Hochsehule in Bern
gehalten warden sollen. 1861-62.
37. Die CJrOBOOpie am Krankenbette.
Inaugnral dissertation vorgelegt der hohen
medizinischen Fakultat Pern, von Dr.
Adolf Zeigler. Pern. lSiil.
88. Behandlnng dea akuten Oelenk-
rheumatisuius mit Veratrin. Inaugural
A Hai
In Than. 1861.
3L>. Del i
done Inau^urale da i
Stud. J oris. Bellinzona I
1". i Operative Surgery in
the ]'. Being the I
< Operations performed I
Py A. Prmhard, F.R.I
London : Richards
pp. 171.
41. The Examination ot the Chest, in
a Series of Tables. By G N. Edwards,
M.D., &e. Lomlon : Churchill.
Royal - 1
4 2. On Long, Short kk Sight,
and their Treatment by the Scientific Use
ofSpeetac I j J. S. Wells, M.D., &c.
London: Churchill. 1862. Royal.
pp. 112.
43. Sixteenth Annual Report of the
Devon Lunatic Asylum. 1301. bvo,
pp. 2l>.
14. Transactions ol the Levant Qua-
rantine Association of Constantinople.
Vol. 1. Part I.
45. Psychological Inquiries. The Se-
cond Part. Being a Series of 1
in i inded to illustrate some points in the
Physical and Moral History of Man.
Py Sir Benjamin C. Prodie, Part.
London : Longmans. 1SG2. Leap. pp.
4»i. Essays ou Scientific and other
subjects contributed to the Edinburgh
and Quarterly Reviews. Py Sir H.
Holland, Part., M.D., &.c. London:
Longmans. lSb*2. 8vo, pp. I
47. Transactions of the London Ob-
stetrical Society. Vol. 111. L861. Lon-
don : Longmans. Svo, pp. 4M).
NOTICES TO CORRESPONDENTS.
The next number will contain a Retrospect of the Progress of Medicine during the
Last Decade, prepared by R. D. Lyons, M.D., Professor of the Practice of Medicine
in the Catholic University and Physician to Jervis Street Hospital. Retrospects on
Psychological Medicine, Therapeutics and Materia Medica, and on Midwifery, Physio-
logy, Ophthalmic Surgery, &c, &c, will follow.
We have been obliged to hold over several Reviews and Original Papers.
Books and Periodicals published in Northern Europe and the German States,
intended for our Journal, should be transmitted "For the Editor of the Dublin
Quarterly Medical Journal, care of Messrs. Tbubneb and Co., London," throwjh I
Correspondents in the principal Towns on the Continent. Our Correspondents in
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AMERICAN Books and Journals often come to hand with such an amount of
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I N D E X
TO THE TIIIKTY-TIMID VOUJ.MK.
ACHORION Schbnleini, 401.
Acupressure needles, 4 1:!.
Air, measurement of cooling power of,
273.
Alopecia areata, 402.
Alihaus, Dr., on carbonic acid in mineral
waters, 75.
Amputations, 1S7 — through condyles,
187 — in the child, 188 — in gangrene,
313.
Anchjdosis of joints, 186, 470 — compli-
ed, of leg, 22, 485 — of hand, 483,
486— of thigh, 487.
Anderson on parasitic affections of the
skin, Rev., 401.
Anesthesia, local, 414.
Aneurism of aorta, Mr. Macnamara on,
203— Dr. Bernard on, 231— Dr. Finn
on, 236— treatment of, 426.
Ankle, resection of, 67, 185— amputation
at, Syme's and Pirogoffs, 99, 188—
caries of, 470.
Antidotes and specifics, 166.
Anus, diseases of, 100.
Aorta, murmurs in, 324 — obstructive dis-
eases of orifice, 327 — obstructive sten-
osis, 330 — patency, 331 — aneurism of,
203, 231, 236.
Aphonia in tuberculosis, Mandl on,
Trans., 244.
Apparitions, De Boismont on, Rev., 102.
Artery, popliteal ligature of, 22 — effects
of ligature on, 199 — obstruction of, 340
— pulmonary obstruction of, 349.
Arthritis, chronic rheumatic, 180.
Aspirations from the inner life, by H.
M'Cormac, M.D., Rev., 161.
Asvlums, medical superintendence of,
259.
Bandages, 430, 443.
Banks, Dr., on general paralysis of the
insane, 201 — clinical reports by, 356.
Bannon, Dr., on contraction of left auri-
culo ventricular opening, I
J '.catty, Dr., on hydatids of uterus, 4 15.
Belcher, Dr., BiographSceJ sketch of
Marcpuis of Dorchester, by, 238 — on
treatment of psora, 47 J.
T. H.i t Clinical and Pathological Society,
transactions of, 483.
Bennett, Dr., on ligatured artery, 1
Bernard, Dr., on aneurism of aorta, 231.
Bisulphites Polli, on use of, in zymotic
diseases, Her., 367.
Bladder, irritable, from uterine disease,
Dr. Churchill on, 196 — extroversion of,
489.
Boismont, De B., on hallucinations, &c,
Rev., 102.
Bones, resection and removal of, 14, 442
— formation of new, 98 ; and joints,
diseases of, 177.
Bowman, introduction to practical che-
mistry, by, Rev., 403.
Brain, concussion of, 430 — abscess, 430.
Bread, nutritive value of, compared with
milk, 414 — gluten, 414.
Browne, Dr., on cataract, 483 — on en-
chondroma, 483 — on compound fracture
of tibia and fibula, 485 — amputation of
hand, 487 — of thigh, 487 — on diseases
of femur, 488 — on extraversion of
bladder, 489 — on excision of tonsils,
490.
Burns, deformity from cicatrix, new
operation for, 2, 6, 7, — 441.
Butcher, Mr., reports in operative sur-
gery by, 1.
Byrne, Dr. J. A., on rupture of uterus,
and recovery from, 219.
Cancer, origin of, l»i7, 16S — specimen of,
Calculus, renal, 47S — urethral in female
Carbonic acid in mineral waters, 75.
Carpus, resection of, I
CartOagee, diseases of, 177.
Cataract, Otpcnlo lenticular, 1 •_' '
I
I .in, malignant disflase of, S
< . m uf, 101 — cellular patho]
:.
I ii8try, papen on, by Max. Sim
, i I 1 manuals «.(', A V., 4U3 —
ivy," 404— nomencla-
ture of, 40 1.
Churchill, Dr., <>ii reflex irritations from
Utei
I rix, deformity from, after burns,
-Mr. Butcher on, 2, 0, 7, ill.
Cirrhosis of liver, 206, 17-
Claviole, fracture of, 484
Clitoris, &c, tumours of, Dr. H'Clintoek
on, •
College of Physicians in Ireland, trans
actions of, 193.
Colles, Mr. on radical cure of hernia,
Collis, M. 11., retrospect of progress of
Surgery, 168, 417 — on cancer, 200.
Consumption, its early and remediable
ges, Smith on, Rev., 108 — pretuber-
cular stage, -ii »i< expansion of the chest,
415 — abscess opening in intercostal
space, 455.
Co>.',v«', on syphilis, gonorrhea, and gleet,
.. 135.
Cork Medical and Surgical Society, trans-
actions of, 227, 17i».
Corrigan, Dr., on treatment ofhydropho-
in Salamis, 198 — on medical super-
bendenoe of asylums, 261.
Crampton, Sir 1'., method of treating
fracture of radius, 128 — memoir of, 247 .
I >up, tracheotomy in, 441.
Oullerier, on venereal diseases, Rev., 406.
I k, !>r., memoir of, 255.
Cyclopia, 72.
Damp, cooling p< wer of, -J 7 7.
Davies, Redfern, on radical cure of hernia,
Debout, Dr., on prothesis and autoplasty
in cleft palate, 490.
Deformity after burns, operations. 2, 6,
7,-411.
I ' aeration of tissues, 165, 171, 340.
De Ivied, on some of the watering places
and other health resorts of Switzerland,
87.
Development, doctrines of, 10 l.
Diabetes mellitus, Dr. Hughes on saccha-
rine treatment of, 301 —pathology of,
- Dr. Moore on, 453.
Diet, daily scheme of, in consumption,
414.
Diphtheria, 480.
1 -e, lectures on germs and vestiges,
and prevention of, by Dobell, Rev,
149 — a disordered condition, 1
!i>, reduction by manipuls
I stion, II
1 11, 1- ctun
ation, /.'
ducal
tch of, by Di
I r. V. s.,
'• Drainage " in erapj
Dreams, De Boismont, on, Her., 102
Drunkards, reformatories for, i
Duncan, Dr. J. P., on disease oi i
and apoplexy, 145— on embolus, 149.
Ear, cellular polyp as of, Mr. Hildig
806.
i ieur, 143.
Embolus, 19.
Empyema, paracentesis and drainage in.
856 ; iodised injections in, 861.
Enohondroma of hand,
Encysted tumours, Dr. Thorpe on, -1
Epistaxis, Mr. Macnamara on, 2S —
varieties of, 29 — Causes of, 29— from
blood di I— from mental emo-
tion, 82 — from cardiac d :>4 —
from splenic disease, 84— from renal
disease, 35— from cerebral atfectioi.
— source of blood in, 40 — symp:
of, -11 --treatment of, 43 — in h
Epulis, i
Ethical writii) . lid.
Examinations, periodical, for preventing
disease, Dobell on. Rev., 149.
Excision of joints, 180.
Exta-<y, De Boismont on, Rev., 102.
Extra-uterine fetation, 402.
Eyes, plurality of, 73.
Eat! rations, 171, 340.
E:i\ OS, .
Femur, disease of, 488— resection of, 14,
184— fracture of, 95, 433, 430, 41
Fermentation, morbific, diseases depend-
on, and their treatment, Polli on,
Fetation extra-uterine, 402.
Finn, Dr., on aneurism of thoracic aorta,
236 - on calculus in female urethra, 479.
da, \ esico vaginal, -1
Foy, memorial de therapeutique, Rev. 140.
Fractures, 430 — of radius, 127 - of skull,
281, 429 — ununited, 96 — compound,
followed by gangrene, 311 — starched
bandage in, 430 — of femur, 433, 437
— of patella, 434 — statistics of, 43.") —
of clavicle, 4S4 — of humerus, 487 —
compound of tibia and libula, 4 So.
Franks on epistaxis, 30, 87.
Gangrene, acute, after compound fracture,
Index
517
Dr. Wilmot en, 811 — imputation in,
818 — from nricii.-il obstruction, 840.
Gardiner, Dr., on a difficult and oompli<
oated Labour, 476.
Gely, on oath* terii tn, ft v.,
Germs and resti ei <>i" disease, Dobell on,
ft ., 1 19.
Glaucoma, IS I.
Gonorrhea and <-leet, W. Cooke on, Rev.,
1 :'..'>— and syphillis, aphorisms on, 172
— treatment of, J 7<>.
Gordon, professor, on fracture of radios,
Rev., 127 — on fracture of clavicle, 484
— Dr. Samuel, reports of rare cases,
840.
Gunshot wounds, 186.
Halahan, Dr., on mechanism of labour,
407.
Hallucinations, De Boismont on, Rev.,
102.
Hamilton, Mr., on osteosarcoma, 208 —
Dr. Edward on intra-capsular fracture
of the femur, 450 — on syphilitic
laryngitis, 456.
Hare lip, 439.
Harrison, Dr., memoir of, 249.
Harrowgate waters, Dr. Osborne on, 198.
Haughton, Rev. S., on use of nicotine
in tetanus, 429.
Hayden, Dr., on tubercular abcess open-
ing through intercostal space, 445.
Head, injuries of, 289, 429 — deformed,
460 — congenital tumour, 464.
Health resorts and watering places of
Switzerland, Dr. De Ricci on, 87.
Heart and vessels, commentaries on
diseases of, by R. D. Lyons, 320 —
intermittent, without organic disease,
320 — feeble, with hypochondriacal
symptoms, 322 — obstructive disease of,
445 — disease of valves.
Hernia, reduction of, 191 — radical cure,
60, 189, 191, 243— truss for, 190—
strangulated, operations for, 192.
Herpes, 402.
Heyf elder, Dr. Oscar, on resection of
astragalus, 67.
Hildige, Mr., on cellular polypus of ear,
306.
Hip joint, disease of, 179 — resection of,
184 — dislocation of, 436.
Holden's manual of dissection, Rev., 130.
Horses liable to epi>taxis, 60.
Hospital reports, by Dr. John Hughes,
296.
Houghton, Mr., on occlusion of the
vagina, 240.
Hulke on ophthnlmoscope, Rev.. 119.
Huxham on epi.~ta.xis, 31.
Hydatids of uterus, 41.1.
Hypodermic injections, 444.
Hydrocele^ radical cure, 429.
Hydrophobia, treatment of In Selamis,
Inflammation og fatty dej."
tion, 171 tn atment <>\', 177.
I D M' ni'.iiain, 2 !•"».
Inoculation, syphilitio, as a cup. 17.'
a.s a diagnoei ic, L'
In. ane, paralyaia at, 201.
Joints, anchyli sod, i 0 a, or p-
section < > t", L80 ampntation through,
l 7 - hip, diet a e <>f. 1 7'.' and b
diseases of, 1 77— treatment of, l;
Ki<l<l, Dr., on epistaxis from renal dis-
ease, 30 — on a congenital tumour of
the head, 464.
Kidney, calculus in, 478.
Knee, resection of, 182.
Labia, &c, tumours of, Dr. M'Clintock,
on, 209.
Labour, mechanism of, 467 — difficult and
complicated case of, 476.
Laryngitis, syphilitic, 456.
Leg, complicated amputation of, 22.
L'Estrange's truss, 190.
Life, doctrines of, 163, 165.
Ligamentum teres, action and vascular
supply of, 134.
Ligature of popliteal artery, 22 — effects
of, on arteries, 199.
Liston, method of holding knife in litho-
tomy, 422.
Lithotomy, 420 — rectangular, 420 — Al-
larton's, 421 — position of the knife,
422— statistics, 423— in the female, 423.
Liver, cirrhosis of, 206, 472 — tuberculosis
of, 207.
Lunatic Asylums, medical attendance of,
259.
Lyons, R. D., commentaries on diseases
of heart and vessels, 320 — on a double-
bell stethoscope, 364.
M'Clintock, Dr., on tumours of labia,
clitoris, and vagina, 209 — on fibrous
tumour of the uterus, 451.
M'Cormac, aspirations from the inner
life, Rev., 161.
Macnamara, Mr., on epistaxis, 28 — on
aneurism of aorta, 203.
MacSwiney, Dr., on cirrhosis of liver,
206 — on fibrous tumour of uterus, 227
— valvular disease of heart, A 57.
Malformations and congenital diseases of
organs of sight, 71.
Mandl, on aphonia in tuberculosis, Trans.,
244.
h, Sir H., memoir of. 251.
M:i\;llarv bon< -. rCSCOtion of. 1S5.
Bfeaecins, Morabsfe . /.'••.. 161.
eutique, bj F'>y,
ury in Byphilia, ttion,
rvatious, value ami
Qcy ofj 1'
>sporon, Audouini,
., nutritive value of, i 14.
leformed cranium,
Mineral iraters, carbonic add in, 75.
M QOCUluS, ,
Montgomerj, Dr., memoir of, 2
development
e, Dr., on tuberculosis, 207 — on
diabetes, 4 53.
Blarney, l>r., on the statistics of the
mortality of fracture of the skull, and
t op< ration, 28 1 .
Myocarditis, pure uncomplicated,
. plugging of)
due in tetanus, 420.
i
I — Ui»e
.
Polli on di depending on m
. i their tr< atm
i :
Polypus, cellular
com labour,
Popham, Dr., ann
Popliteal artery, tigatui
Porrigo, 401.
I >r., memoir of) -j.~
Products, morbid, 167.
Proth
tate, aba -j \.
l, treatment of, 17 l.
Pulmonary artery, obstruction of,
[.
Pulse, irregular and intermittent, 8
Pus, origin of, L67, 1 70.
Pyemia, successfully treated, 25.
Obstetric Society of Dublin, reports of,
BO.
onor, Dr., on diphtheria, ISO.
Odling, manual of chemistry by, Ju c, 103.
Opthalmia, gonorrheal, 177.
Opthalmoscope, BEulke on, Jur., 119.
Optic nerve, malformation o\', 71.
Osborne, Dr., on the use of llarrov
wat -on the employment of a
heated thermometer for the measure'
ment of the cooling power of the air on
the human body, 'J.J'o, 414.
Osteitis, 178.
Osteosarcoma, Mr. Hamilton on, 2i>S.
Palate, cleft, 436 — Debout on prothesis
and autoplastv in, 490 — Preterre on
artificial palate, 495 — on the manage-
ment of children born with, 502, 508.
Patella, fracture of, 434 — Malgaigne,
spikes tor, 434.
Paracentesis thoracis, 35<>, 443.
Paralysis of Insane, Dr. Banks on, 201.
Parasitic affections of skin, 401.
Pathological Society, proceedings of, 100,
450.
Pathology, surgical, 163 — cellular, Vir-
chow's \ lews, 164.
Peel, Sir Robert, deputation of visiting
physicians of asylums to, 250.
Perineum, ruptured, 438.
Phthisis — see consumption.
Phymosis, operations for, 417.
Physicians, College of, transactions of the,
198, 444 — ethical writings of,
101.
Pirogoff's operation on ankle, 100, 188.
Quarantine, report on, Re».t 112.
Radius, fracture of, 127, 435.
Rare eases, reports of, by Dr. S. Gordon,
840,
Read, on placenta previa, Rev., 891.
Rectum and annus, disoascs of, loii.
Reformatories for druukan ;74.
tion and removal of bones, Mr.
Butcher on, 14 — Dr. Heyfelder on
Retina, malformations of, 71 — floating.
120.
Retrospect of surgery, 103, 417.
Rheumatic arthritis, chronic, 180.
Ivynd, Mr., memoir of, 254.
101.
ula, resection of, 1 "5.
Sciatica, from uterine disease, Dr.
Churchill on, 195, 14 1.
Series-lines, U3.
Sight, malformations and congenital
dis< sees id' the organs id', 71.
Simpson, Dr., on chemistry, /far., 144.
Skin, parasitic affections of, Rev., 401.
Skulk on the statistics of the mortality of
fra( cures of, and effects of operation,
281— deformed, 160.
Smith on consumption, its early and
remediable stage, Rtv , 408.
Smvly, Mr. J., on plugging nares, 1
. iodide of, in tertiary syphilis, 170.
Somnambulism, De Boismont on, Rev.,
lt>2.
Specifics and antidotes, 165.
Starched bandage, 430.
Stethoscope, a double-bell, 364.
Index.
519
Styptics, III.
Surgery, retrospect of progn b of,
during the last decade, 163, H7 path-
ologyi 168 -plastic, 168 orthopedic,
minor, I 12— elinieal, l>v Sj me,
i; .,95.
Swimming, real limit i to power of, 2
Switserland, watering places and h
resort i at, 87.
Byrne, clinical surgery, /.'<<-.. on Fracture
of t h i lt 1 1 bone, ' 6 ununited Eract
on amputation at ankle, 99 — on
diseases of rectum and anus, 100 — on
radioal cure of hernia, 190.
Syphilis, relative influence of nature and
a. . in cure of, \V. Cooke on, Rev., 135.
Syphilis and gonorrhea, aphorisms on,
172— variety of primary sores, 174 —
tment, 175 — hy inoculation, 175
— by mercurial fumigation, 175 — of
tertiary. 1 7'».
Synovitis, 177.
Talipes, 412.
Tendons, reparative process in, 441.
Testis, cystic disease of, 421.
Tetanus, nicotine in, 429.
Therapeutique, memorial de, Rev., 140.
Thermometer, heated, for measuring the
cooling power of the air, Dr. Osborne
on, 273 — animal heat, 276, 444.
Thorpe, Dr., on encysted tumours, 81.
Tibia, resection of, 19— compound frac-
ture of, 4S5.
Tinea, 401.
Tissues, degeneration of, 165, 171.
Tonsils, excision of, 490 — effect of excision
on sexual development, 490.
Tourniquets, 443.
Tracheotomy, 441, 456.
Truss, by L'Estrange, 190.
Tubercle, origin of, 168, 170 — of liver,
207.
Tuffnell, Mr,, case of extra uterine feta-
tion, 462.
Tumours, nature at, 1 69 oflabii
and ragina, 209 fibroti , of at
227 < qi aital, < 1 1
m
Urethra, t riot are of, 1 1 - pei ai a] i otion
of, i L9 plitting, (Holt's method)
I oe disease, I Jr. ( Ihurchill on, refles
irritation fri
Uterus, rupture of, and recovery, l»y
Dr. .1. A. Byrne, 219 -fibrous tumour
of, Dr. BdaoSwiney on, 227 — Dr.
M 'Clin tuck on, 451.
Vagina, &c, tumours of, Dr. M'Clintock
on, 209 — occlusion of, by Mr. Hough-
ton, 240— fistula, 438.
Veins, varicose operations for, 424.
Venereal diseases, modern pathology
and treatment of, Watson on, Rev., 135
— Cullerier on, Rev., 406.
Vestiges and germs of disease, Dobell on,
Rev., 149.
Virchow's cellular pathology, 164.
Visions, De Boismont on, Rev., 102.
Vitreous body, malformation of, 71.
Waters, mineral, carbonic acid in, 75 —
of Harrowgate, 198.
Watering places of Switzerland, De
Ricci on, 87.
Watson on modern pathology and treat-
ment of venereal disease, Rev., 135.
Wilde, W. R., on malformations and
congenital diseases of organs of sight,
71.
Willett, Dr., on cirrhosis of liver, 472 —
on renal calculus, 478.
Wilmot, Dr., on acute gangrene from
compound fracture of leg, 311.
Woillez, Madame, medicines moralistes,
by, Rev., 161.
Wutzer's instrument for cure of hernia,
modified by Davies, 65.
Zymotic diseases, Polli on use of bisul-
phites in, Rev., 367.
1
R
31
185
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